We report the use of bilateral surgical decompression of the internal auditory canals to treat hyperostosis cranialis interna in an eight-year-old girl presenting with bilateral facial palsy due to hyperostosis cranialis interna.

Using a middle fossa craniotomy approach, both internal auditory canals were unroofed and cranial nerves VII and VIII were decompressed, with a one-year interval between sides. The mimic function recovered. One year post-operatively, the right and left facial sides had been restored to House–Brackmann grades I and II, respectively.

This is the first report of the use of surgical decompression of the internal auditory canal in a case of hyperostosis cranialis interna. Surgical decompression of the internal auditory canal is recommended therapeutically, but may also be performed prophylactically in younger patients with hyperostosis cranialis interna.

Oncogenic osteomalacia, or tumour-induced osteomalacia, is an uncommon cause of osteomalacia. It has been reported to occur in patients with hypophosphataemia due to excess renal phosphate excretion secondary to mesenchymal tumours. Occurrence of this pathological process in the head and neck is extremely rare.

Case report and literature review.

We present a case of a 73-year-old woman with tumour-induced osteomalacia. She was initially followed by the endocrinologists for osteomalacia and pathological fractures. An indium-111 pentetreotide scan showed activity in the left pterygopalatine fossa. A mass was endoscopically resected, and the histopathological appearance was consistent with a haemangiopericytoma. Following surgery, the patient's hypophosphataemia and vitamin D deficiency corrected and her symptoms resolved.

Oncogenic osteomalacia, or tumour-induced osteomalacia, is a rare entity in the head and neck. Current research is elucidating the mechanism by which phosphaturic wasting occurs. In most patients, symptoms resolve once the offending tumour is removed.

We report three generations of one family suffering from bilateral conductive hearing loss due to a congenital anomaly of the incus and stapes fixation.

All three female patients presented with similar symptoms and findings of hearing impairment since birth. Their computed tomography findings were the same. An abnormally shaped incus, fixed stapes and hanging tympanic portion of the facial nerve were seen at surgery. Stapedotomy could not be performed because the hanging facial nerve blocked the operating field.

Although several cases of familial ossicular anomaly have been reported, this is the first report of an incus anomaly and stapes fixation combined with a facial nerve anomaly.

We present the first reported case of ultrasound-guided aspiration of a laryngopyocoele in a patient with acute airway obstruction.

A 71-year-old woman was diagnosed with a right-sided laryngocoele. Six weeks later, the patient was admitted as an emergency with a three-day history of increasing dyspnoea and stridor. Neck examination revealed a large, right-sided, soft neck mass, centred at level III, measuring approximately 10 × 5 cm. Fibre-optic laryngoscopy revealed a large, smooth, inflamed, right supraglottic mass obscuring the laryngeal inlet. The patient was taken directly to the radiology department, where ultrasound imaging confirmed a laryngopyocoele. Under ultrasound guidance, a 21-G needle was directed into the cyst and 30 ml of pus was aspirated. The dysphonia and stridor resolved immediately. Six weeks later, the patient underwent definitive surgical excision of the laryngocoele.

Laryngopyocoele is a rare diagnosis. It can present as an acute airway emergency. We present the first reported case managed by ultrasound-guided aspiration, which averted the need for endotracheal intubation or tracheostomy.

We report a very rare case of prostatic metastasis in the internal auditory meatus, which disappeared with treatment.

An elderly man presented with a history of hearing loss, dizzy spells and, more recently, facial palsy. He also complained simultaneously of urological symptoms, which on investigation revealed advanced, metastatic prostate cancer. Radiological investigation, in the form of magnetic resonance imaging, revealed an internal auditory meatus mass which resembled an acoustic neuroma. The patient was treated with hormone injections.

Tumours of the internal auditory meatus and cerebellopontine angle are mostly primary. Rarely, metastatic deposits have been described in this region, from squamous cell carcinoma, malignant melanoma, malignant parotid oncocytoma, renal carcinoma, and lung and thyroid primaries.

To our knowledge, this is a very rare report in the world literature of prostatic metastasis to the internal auditory meatus. We discuss the common presenting features, investigations and treatment options for metastatic prostatic tumours of the internal auditory meatus and cerebellopontine angle.

Paediatric foreign bodies may present with vague and nonspecific symptoms. It is important to have a high index of suspicion when managing such cases.

We report the case of a nine-month-old infant who presented with a wheeze, cough and fever following ingestion of a needle.

This patient developed pericardial tamponade as a consequence of the needle ingestion, and required a thoracotomy for retrieval. We discuss the pathophysiology involved and the surgery required.

Pericardial tamponade is a rare but potentially fatal manifestation of an ingested foreign body.

Peritonsillar abscess (quinsy) is one of the most common ENT emergencies. A 2002 UK audit of quinsy management revealed that an average ENT department treated 29 cases annually; the most common treatment was needle aspiration with intravenous antibiotics, and culture of the aspirate was often performed routinely. The aims of our study were to evaluate the value of routine culture of quinsy aspirates, and to establish whether the information thus gained was clinically useful.

We examined the notes of patients admitted with quinsy to two hospitals in south-west England, from January 1998 to January 2004 in one hospital and from January 1995 to January 2005 in the other. A total of 577 cases was found. Aspirated pus had been sent for culture in 119 (21 per cent). These cases were examined in more detail.

Of the 119 patients, 78.2 per cent (93/119) were treated with either a cephalosporin or penicillin, plus metronidazole. Streptococcal species were cultured in 43.7 per cent (52/119) and anaerobes in 23.5 per cent (28/119; of these cultures, 5.9 per cent (7/119) were pure anaerobes only). All the anaerobes were sensitive to metronidazole. One of the 119 cultures, growing aerobic bacteria, was resistant to penicillin; however, this patient improved clinically on a combination of penicillin and metronidazole. No patients had their treatment changed because of culture results.

There appears to be no need to routinely culture quinsy aspirates, based upon our findings (of 16 hospital years) and previous studies (which found no recorded episodes of treatment change as a result of culture sensitivities). The combination of penicillin or a cephalosporin, plus metronidazole appeared to be theoretically effective in 99.2 per cent (118/119) of our specimens; this finding is supported by other studies. However, the rare but potentially life-threatening complications of quinsy must be recognised.

Radiotherapy is an important treatment modality for head and neck tumours. One of its major drawbacks is post-treatment salivary gland hypofunction. This study was performed to objectively evaluate the salivary gland function in post-irradiated head and neck tumour patients.

We performed a cross-sectional study of 30 patients with head and neck tumours who had received radiotherapy. Unstimulated and stimulated whole salivary flow rates were assessed in these 30 patients, and compared with those of 30 normal subjects. Unstimulated whole saliva was measured by the draining method, while the spitting method was used to collect stimulated whole saliva.

Both unstimulated and stimulated whole salivary flow rates were significantly reduced in the irradiated patients, compared with the normal subjects. This difference was statistically significant (p = 0.0001).

Salivary function in post-irradiated head and neck tumour patients (assessed as salivary flow rates) was significantly reduced compared with normal controls, suggesting marked salivary gland hypofunction.

Warfarin-induced skin necrosis is a rare but recognised complication of this drug. The condition predominantly affects the breasts, buttocks and thighs of obese, peri-menopausal women. We present the case of a patient with the condition in an unusual site, and we discuss the management challenges involved.

An 82-year-old man presented to the ENT department with a diagnosis of pinna haematoma. There was no history of trauma or infection. The patient was taking warfarin long-term for recurrent deep vein thrombosis. Two weeks prior to admission, the patient had had a loading course of warfarin following surgery. Multiple clinical teams were involved in treatment. The only abnormal laboratory investigation was a low protein S level; biopsy showed skin necrosis.

In this case, the unusual presentation created diagnostic confusion, and may have precipitated aggressive surgical debridement. However, a more conservative management strategy was used, which we would recommend in future.

We report a case of familial medullary thyroid carcinoma in an 87-year-old woman, despite the patient having a high-risk codon 620 mutation.

Medline and PubMed were searched for cases and literature reviews relating to the following keywords: ‘codon 620’, ‘medullary thyroid carcinoma’, ‘multiple endocrine neoplasia’ and ‘RET proto-oncogene’.

We report the case of an 87-year-old woman who presented with a goitre, later identified as medullary thyroid carcinoma. Genetic analysis revealed a RET proto-oncogene codon 620 mutation. Genetic testing has revolutionised the management of medullary thyroid carcinoma. The genetic basis of hereditary medullary thyroid carcinoma lies with the RET proto-oncogene. Several disease-causing mutations of this gene have been identified and their clinical prognosis described. The penetrance of these mutations is high; as such, carriers progress to develop medullary thyroid carcinoma at a young age. Mutations at the codon 620 position are classified as high-risk for early development of medullary thyroid carcinoma; thus, the current recommendation is for prophylactic thyroidectomy at five years of age.

In this case, the progress of hereditary medullary thyroid carcinoma was unique, considering the late presentation of medullary thyroid carcinoma despite the presence of the high-risk RET proto-oncogene codon 620 mutation. The authors wish to highlight the importance of this case, as it may present a counter-argument to the current recommendations for early, prophylactic thyroidectomy in codon 620 mutation carriers in order to prevent early development of medullary thyroid carcinoma.

We report an extremely rare upper airway complication of oesophageal stent failure.

A 58-year-old woman presented four months after having a covered (anti-reflux valve type) oesophageal stent placed for a benign oesophageal stricture. Abdominal radiography showed a broken fragment at the gastroesophageal junction and another fragment in the rectum. On presentation, the patient had pneumonia with sepsis which required intensive care management. After recovery, she developed sinus symptoms of facial pain, green nasal discharge and bilateral hearing loss. ENT review revealed bilateral otitis media with effusion. Flexible naso-endoscopy found a stent fragment lodged in the nasopharynx. The wire mesh fragment was removed under general anaesthetic and bilateral grommets inserted. The patient's symptoms resolved.

To our knowledge, this is the first report in the world literature of a broken and migrated oesophageal stent presenting with chronic sinusitis and bilateral hearing loss. This case highlights the importance of examining the upper airways in such cases, and the need for further, long term studies of the complications of metallic, expandable stents.

We report an extremely rare case of Langerhans' cell histiocytosis involving isolated cervical lymph nodes, and we discuss the diagnosis and treatment of this infrequent disease.

We present a case report and literature review concerning this disease entity.

A 54-year-old man presented with persistent, multiple, left neck masses. Histopathological study of lymph node specimens showed proliferation of Langerhans' cells coupled with eosinophilic and neutrophilic microabscesses. Positive immunohistochemical staining for Cluster of Differentiation 1a (CD1a) in Langerhans' cells confirmed the diagnosis. No other abnormalities were noted on a series of image studies. The patient was managed with ‘watchful waiting’ without subsequent therapy. The neck lesions regressed gradually over time, and the patient did well over a two-year follow-up period.

The clinical presentation of Langerhans' cell histiocytosis is highly variable, and the choice of treatment depends on the involved organs. Definitive diagnosis depends on identification of characteristic immunohistochemical or ultrastructural features of the biopsy specimen. Watchful waiting may be an effective management strategy in cases of adult isolated lymph node Langerhans' cell histiocytosis, due to its possible spontaneous regression.

We report a rare UK case of laryngeal leishmaniasis, mimicking laryngeal candidiasis, associated with long term steroid inhaler use.

Case report and review of the world literature concerning leishmaniasis.

Laryngeal leishmaniasis is a protozoal infection which is rare in the Western world. It is becoming more common, however, with increased foreign travel. The disease can be difficult to diagnose histologically, and diagnosis is often delayed because of its rarity. It can mimic malignant laryngeal disease, and patients may therefore be subjected to significant and inappropriate treatment interventions.

A diagnosis of leishmaniasis should be considered if initial treatment for persistent hoarseness is ineffective, particularly in a patient who is at low risk of malignancy.

Post-tonsillectomy complications are common. The majority are easily recognised because of their frequent occurrence and can be managed as required. Infrequent complications may be misdiagnosed or managed inappropriately. We present a previously unreported complication of tonsillectomy.

A 45-year-old Afro-Caribbean man underwent routine tonsillectomy. Eight weeks post-operatively, he developed an ulcero-necrotic lesion of the tonsillar fossa. Subsequent investigation revealed that he was human immunodeficiency virus positive. It is highly likely that the patient's underlying immuno-compromised state, secondary to human immunodeficiency virus infection, contributed to this ulcero-necrotic lesion.

This case highlights the importance of clinician awareness of rare complications of tonsillectomy, in order to facilitate identification and appropriate investigation.

We present a rare and clinically relevant anomaly of the sphenopalatine artery in relation to its blood supply of the nasal mucosa, with implications for the management of epistaxis.

Case report and review of the world literature, using Medline through Pub Med (1950–2005), EMBASE (1980–2005) and Ovid (1958–2005), searching for papers using a combination of terms including ‘spheno-palatine artery’, ‘anterior ethmoidal artery’ and ‘epistaxis’.

In the presented case of refractory epistaxis, endoscopic and subsequent endovascular management failed to identify a significant supply from the sphenopalatine arteries bilaterally. The main supply was found to be from the anterior ethmoidal arteries.

After a detailed search, the authors failed to locate any similar case in the English literature.

To report the characteristics, prognostic factors and treatment outcomes of 102 patients with squamous cell carcinoma of the oral tongue treated and followed up at a single institution over a 25-year period.

This retrospective study was carried out by auditing the medical records of 102 patients diagnosed with squamous cell carcinoma of the oral tongue and treated at our institution between 1982 and 2007. Patient follow up ranged from nine to 310 months (median 35 months). Fifty per cent of the patients were treated with surgery followed by a combination of chemotherapy and radiotherapy (43.1 per cent received concurrent chemoradiation and 6.9 per cent received sequential chemotherapy and radiotherapy), whereas 29.4 per cent received surgery followed by adjuvant radiotherapy alone. The remaining patients (20.6 per cent) did not undergo surgery and were treated with definitive radiotherapy with or without chemotherapy.

There were 48 men and 54 women. The age at presentation was 19–85 years (median 57 years). The peak incidence was observed between 60 and 70 years. Resection margins were clear in 75 per cent of patients and involved in 25 per cent. Stage I disease was found in 11.8 per cent of patients, stage II in 34.3 per cent, stage III in 22.5 per cent and stage IV in 31.4 per cent. The five-year disease-free survival and overall survival were 65.7 and 72.5 per cent, respectively. Thirty-five patients suffered recurrence after treatment, 74.0 per cent of them at the site of initial cervical nodal involvement. Univariate analysis for overall survival revealed the following as prognostic factors: treatment schedule (surgical vs non-surgical; p < 0.001); age (<60 years vs ≥60 years; p = 0.038); extent of cervical lymph node involvement (p = 0.015); primary tumour stage (p < 0.001); node stage (p = 0.034); and disease stage (p = 0.013). However, on multivariate analysis, only non-surgical treatment (p = 0.001) and advanced disease stage (p = 0.05) were found to have a negative influence on survival.

Our limited data suggest that, in Iran, squamous cell carcinoma of the oral tongue tends to present at a locally advanced stage, with a high frequency of locoregional failure and a poor outcome. Combined modality therapy should be considered for the majority of patients with squamous cell carcinoma of the tongue.

The inhaled sharp foreign body is usually amenable to bronchoscopic extraction. When this fails, management poses a challenge. We present a logical approach to the inhaled pin inaccessible to the bronchoscope.

A 12-year-old girl presented to the accident and emergency unit after accidentally inhaling a pin. Multiple attempts with both rigid and flexible bronchoscopy failed to access the pin, which had lodged distally in the anteromedial basal segment of the left lung. Eventually, the pin was extracted at thoracotomy.

We discuss the reasons for extracting such pins, as opposed to leaving them in situ, and when to proceed from endoscopy to open surgery. Such knowledge is useful, not only to guide the multidisciplinary team in their combined approach to this unique challenge, but also to explain to the patient the rationale for the proposed treatment protocol.