Verrucous carcinoma is a variant of well differentiated squamous cell carcinoma characterised by an exophytic, warty growth which is slowly but locally invasive and which can cause extensive local destruction if left untreated.

We report the first known case of veruccous carcinoma of the paranasal sinuses with rapid orbital invasion. A 58-year-old man presented with right-sided nasal obstruction, a huge right intranasal lesion, intractable dacryocystitis and cutaneous involvement of the nasolacrimal sac region. The tumour was partially removed using an endoscopic transnasal approach. Post-operatively, and while waiting for the histological result, the patient developed signs of rapid invasion of the orbit, with uniocular visual acuity deficit. He underwent combined radiochemotherapy, with a moderate response.

Knowledge of the potentially aggressive nature of verrucous carcinoma may be helpful in early management of intraorbital invasion and salvaging of the eye.

To determine the most effective local anaesthetic method for manipulation of nasal fractures, and to compare the efficacy of local anaesthesia with that of general anaesthesia.

Systematic review and meta-analysis.

Medline, Embase, Cochrane Library, National Research Register and metaRegister of Controlled Trials.

We included randomised, controlled trials comparing general anaesthesia with local anaesthesia or comparing different local anaesthetic techniques. Non-randomised studies were also systematically reviewed and appraised. No language restrictions were applied.

Five randomised, controlled trials were included, three comparing general anaesthesia versus local anaesthesia and two comparing different local anaesthetic methods. No significant differences were found between local anaesthesia and general anaesthesia as regards pain, cosmesis or nasal patency. The least painful local anaesthetic method was topical tetracaine gel applied to the nasal dorsum together with topical intranasal cocaine solution. Minimal adverse events were reported with local anaesthesia.

Local anaesthesia appears to be a safe and effective alternative to general anaesthesia for pain relief during nasal fracture manipulation, with no evidence of inferior outcomes. The least uncomfortable local anaesthetic method included topical tetracaine gel.

To investigate the ventilation and drainage mechanism of the middle ear.

Prospective.

We observed 304 (of 337) middle ears with tympanic membrane perforation or myringotomy (102 normal, 90 with otitis media with effusion and 112 with chronic otitis media); 912 observations were recorded overall. Perforations were covered with solution, creating a fluid film, and inspected for gas bubbling at rest, and for outward and inward movement of the fluid film during swallowing. We also noted the inflammatory condition of the ear (i.e. dry, wet or purulent) and the perforation size.

Ears sometimes reacted differently in various sessions. Due to these differences, reactions were classified as ‘types’ of reactions rather than ‘ears’. We refer to 449 ‘types’ of 304 ears. Spontaneous gas bubbling at rest (indicating gas production) was observed in 98 per cent of normal types, 68 per cent of otitis media with effusion types and 65 per cent of chronic otitis media types. Evacuation towards the eustachian tube was observed in 47 per cent, no movement in 46 per cent and outward movement in 9 per cent. During swallowing, inward movement of the fluid film was observed in 74 per cent of normal types, 41 per cent of otitis media with effusion types and 32 per cent of chronic otitis media types.

We found no support for the theory that the eustachian tube supplies air to the middle ear during swallowing. The normal middle ear produces gas which is evacuated by the Eustachian tube. In ears with otitis media, this mechanism appears to be impaired.

The subtotal laryngectomy procedure enables the patient to avoid some of the serious consequences of total laryngectomy without having to relinquish oncological effectiveness. However, the important complication of aspiration may still seriously affect some patients. Many methods of reconstruction have been described in an attempt to avoid or minimise this complication.

Thirty-nine patients (15 with supraglottic laryngeal cancer and 24 with hypopharyngeal cancer) who had undergone subtotal laryngectomy between 2000 and 2006 were included in this study. In all patients, a sternohyoid muscle flap has been used for primary, one-stage reconstruction of laryngopharyngeal defects, following resection of advanced stage lesions. Patients' times to oral intake and decannulation, their speech function and their post-operative complications were reviewed.

The patients' three-year overall survival rate was 46.1 per cent. Their mean time to oral intake was 14 days. Twenty-six patients were decannulated (66.7 per cent). Almost all patients regained their speech function post-operatively, although their voice quality was not as good as before surgery.

Sternohyoid muscle fascia reconstruction leads to optimal repair of subtotal laryngectomy defects and restored laryngeal function.

Although many clinical investigations have found a relationship between hearing loss and diabetes mellitus, the pathophysiology of this effect remains controversial. To date, the mechanisms of hearing loss in diabetic patients have been explained in terms of microangiopathy, neuropathy and encephalopathy. However, many reports indicate that some diabetic complications are associated with oxidative stress related to the diabetes itself. In the present study, we hypothesised that oxidative stress may be a cause of hearing loss in diabetic patients.

The study group comprised non-insulin dependent diabetic patients with no signs of microangiopathy or peripheral neuropathy. The control group comprised sex-, age- and body weight matched, non-diabetic subjects. Auditory function was evaluated using pure tone audiometry and tympanometry. Subjects with normal hearing and sensorineural hearing loss were included in the study, whereas subjects with conductive hearing loss were excluded. Both the study group (n = 63) and the control group (n = 37) were divided into subgroups based on the presence and absence of hearing loss. Oxidative stress was evaluated by measuring serum indicators of protein oxidation and lipid peroxidation, serum levels of nitric oxide and various non-enzymatic antioxidants, and the activity of various enzymatic antioxidants.

The non-insulin dependent diabetic patients had significantly higher serum levels of protein oxidation products, nitric oxide, enzymatic antioxidant activity (i.e. glutathione peroxidase and superoxide dismutase), compared with the control group (p < 0.05). When we compared the groups in relation to the presence of hearing loss, the nitric oxide level was significantly increased in the diabetic group with good hearing, compared with diabetic patients with hearing loss (p = 0.014). In the diabetic group, a clear, negative correlation was observed between serum levels of nitric oxide and vitamins C and E, and hearing impairment (r = −0.395, r = −0.318, r = −0.500, respectively). There was also a positive correlation between serum vitamin C concentrations and hearing levels in the control group (r = 0.417).

These results suggest that oxidative stress may play an important role in hearing impairment in diabetic patients. In this process, increased protein oxidation appears to be more important than lipid peroxidation. Nitric oxide may have a protective effect on hearing, as may some nonenzymatic antioxidants such as vitamin C and E.

Dysphonia is common in children, but practice varies considerably regarding what, if any, investigations are performed and how the condition is managed. Although childhood dysphonia is mostly due to non-serious causes such as voice misuse, very serious pathology such as papillomatosis or malignancy needs occasionally to be excluded, and treatable congenital anomalies such as webs and cysts can be missed. Voice clinics and voice therapy services are now well established in most adult health services in the developed world, but equivalent services for children are less common, at least in the UK.

We retrospectively reviewed the records of all children presenting to our large children's hospital with a primary complaint of dysphonia between January 2001 and October 2007, in order to determine their management, investigations and final diagnosis.

We identified 142 children. Case records were found for 137 (97 per cent). Eight-three children were male (61 per cent) and 54 female (39 per cent). Ages ranged from two months to 15 years (median 5.3 years). In 10 children (7 per cent), hoarseness was congenital, presenting as a hoarse, weak cry at birth. In 15 children (11 per cent), onset of hoarseness was related to a specific surgical procedure. The larynx was visualised by mirror alone in 23 children (17 per cent), by awake fibre-optic laryngoscopy in 27 (20 per cent) and by microlaryngoscopy-bronchoscopy under anaesthesia in 42 (31 per cent). Forty children (29 per cent) did not undergo laryngeal visualisation at any time and were diagnosed based on history alone. A further five (4 per cent) were scheduled for direct laryngoscopy but this was not performed due to resolution of symptoms. Voice abuse accounted for 62 (45 per cent) of all diagnoses.

Childhood dysphonia accounts for a large number of referrals. There is considerable variation in how these children are managed. A more structured approach to diagnosis and investigation would be beneficial, perhaps within the setting of a dedicated paediatric voice clinic.

This paper aims to report our experience with different multichannel cochlear implant devices, and to discuss the outcomes of our cochlear implant programme, together with the problems encountered.

Cochlear implantation was undertaken in 117 patients (35 post-lingual and 82 pre-lingual cases; 70 males and 47 females) over a 12-year period. Three cochlear implant systems were used: Nucleus (22 and 24), Med-El and Advanced Bionics Clarion. An extended endaural incision was used in 78 cases and a minimally invasive approach in 39 cases.

Complications occurred in 16.2 per cent of patients. All patients showed a significant post-implantation improvement in their perception and discrimination of sound and speech. Better results were noted in pre-lingual patients under the age of six years. The cause of hearing loss was unknown in 81 per cent of patients.

The outcomes of our cochlear implantation series are comparable to previous reports. The possibility of an abnormally rotated cochlea should be borne in mind when difficulty is encountered during cochleostomy.

Ossicular chain damage from chronic ear disease is a significant problem in the Australian population. The ideal ossicular chain reconstruction prosthesis has yet to be defined. This paper examines, for the first time, the use of a titanium prosthesis for ossicular chain reconstruction in Australian patients.

Retrospective chart review.

All patients undergoing ossicular chain reconstruction with a titanium prosthesis between 1 February 2002 and 31 March 2007.

Results showed a low complication rate, with only one extrusion out of 55 cases (1.8 per cent). Successful rehabilitation of conductive hearing loss (i.e. to ≤20 dB air–bone gap) was obtained in 85 per cent of the partial ossicular chain reconstruction group and 77 per cent of the total ossicular chain reconstruction group. Pure tone thresholds improved by an average 18 dB in the partial reconstruction group and 25 dB in the total reconstruction group.

Titanium is an ideal material for ossicular chain reconstruction due to its ease of insertion, low rate of extrusion and good functional results.

Throat packs are employed in nasal surgery to prevent contamination of the upper aerodigestive tract. Their use is thought to reduce the risk of aspiration and post-operative nausea and vomiting. However, use of throat packs may also be accompanied by increased throat pain. In order to inform our clinical practice, the evidence base for throat pack insertion was reviewed.

A search was made of the Pubmed database from the 1950s to March 2008. Four randomised, controlled, clinical trials were reviewed.

All the trials had significant methodological weakness. In all but one, no power calculations were done. There were inconsistencies in the measurement of pain and heterogeneity of rhinological procedures. The one adequately powered trial could not demonstrate a difference in post-operative nausea and vomiting with the use of throat packs (β error = 20 per cent).

Further, adequately powered trials are required involving patients undergoing rhinological procedures with a higher risk of blood contamination (e.g. functional endoscopic sinus surgery), in order to provide definitive evidence on the morbidity of throat packs in rhinological procedures.

Laryngopharyngeal reflux is perhaps the most extensively researched laryngology topic of the last decade. It has been suggested that some supraoesophageal symptoms, most notably asthma and laryngospasm, may be associated with night-time, or supine, reflux. The aim of this review was to assess the levels of evidence regarding a correlation between night-time reflux, snoring and apnoea.

A Medline search was performed using the terms ‘reflux’, ‘night-time’, ‘larynx’, ‘gastroesophageal’, ‘laryngopharyngeal’, ‘sleep’, ‘apnoea’, ‘snoring’ and ‘ear nose throat’. The retrieved literature was reviewed, focusing on randomised and non-randomised, controlled, prospective trials. Papers on both paediatric and adult populations were included. Non-English language papers were excluded.

We found no randomised, controlled trials or meta-analyses addressing the possible correlation between reflux and snoring and/or apnoea.

The role of night-time reflux in paediatric and adult snoring and apnoea is well described in the literature, but is based on poor levels of evidence from uncontrolled studies and case reports.

To demonstrate the importance of detailed clinical analysis in the differential diagnosis of a cyst in the floor of the mouth, and to provide an update on current knowledge and treatment of sublingual hydatid cyst.

A 23-year-old man presented complaining of a swelling in the midline of the sublingual region, present for four months and progressively increasing in size. Ultrasonography of the neck revealed a well defined, hypoechoic lesion in the sublingual region, containing a calcific focus. Fine needle aspiration cytology showed numerous round to oval structures resembling brood capsules, with scolices and occasional hooklets. T1- and T2-weighted, multiplanar magnetic resonance imaging scans showed a well defined, multiloculated lesion in the sublingual region.

Hydatid disease may present as a slow-growing cyst in the sublingual region. Aspiration cytology should preferably be avoided until radiological imaging studies are complete. A high index of suspicion is necessary to diagnose hydatid disease in an unusual location.

We report a case of a 70-year-old man of Asian origin with lichen sclerosus et atrophicus affecting the tonsil, which presented as a painful, enlarging, exophytic lesion mimicking squamous cell carcinoma.

We present a case report and a review of the world literature regarding lichen sclerosus et atrophicus.

Lichen sclerosus is a chronic, benign, inflammatory dermatosis of the skin and mucous membranes which mostly affects the female genitalia, presenting as white plaques with epidermal atrophy. The cause is unknown, although a number of aetiologies have been proposed. The prevalence is unknown. Women have been reported to be affected six to 10 times more than men, and the condition has no known racial preference.

Our patient illustrates a rare case of the condition lichen sclerosus et atrophicus; to our knowledge, this case represents the first report of tonsillar involvement of the condition. The case presented a diagnostic challenge.

To assess the incidence of vestibular disturbance in patients after cochlear implantation, and to evaluate the quality of vertigo symptoms.

Prospective, observational study.

Cochlear implant centre at a tertiary referral university hospital, Munich, Germany.

Forty-seven adult patients undergoing unilateral cochlear implantation between 2003 and 2007.

Patients were interviewed post-operatively about vertigo symptoms, using a specifically designed questionnaire. Questionnaire data were used to define patient subgroups based on probable vertigo aetiology. Cochlear implantation was performed via a retroauricular, transmastoidal approach. Thirty-six implants were Cochlear Nucleus 24 devices and 11 were MedEl devices.

Twenty-one (45 per cent) patients reported vertigo symptoms following cochlear implantation. The time of onset was directly post-operatively in the majority of patients. In 90 per cent, the symptoms suggested an otogenic origin. The majority of patients reported paroxysmal vertigo with a duration of seconds to minutes. Typical concomitant symptoms were tinnitus, fluctuating hearing loss and vegetative reactions. Serious disablement by vertigo was rare.

Exposing patients to the risk of possible balance disorders associated with cochlear implantation is justified in view of the hearing rehabilitation achieved, even with today's broader indications for cochlear implantation. However, patients should in any case be informed about the possibility and quality of post-operative vertigo symptoms.

We report a case of vertebral artery dissection following direct laryngoscopy, and we provide an update on current knowledge regarding this condition and its relationship to movements of the neck.

A case report and review of the world literature are presented.

Vertebral artery dissection is an uncommon event leading to stroke. It has been associated with many risk factors, particularly extreme movement of the cervical spine. The pathogenesis of the condition and the true aetiological significance of neck movement are not known.

To our knowledge, we present the first case of vertebral artery dissection following direct laryngoscopy. We highlight the need for caution when considering neck pain in patients after direct laryngoscopy.

To review the management, causative organisms, morbidity and mortality of intracranial abscesses secondary to sinus and ear disease.

Retrospective, case note review of suppurative intracranial complications of ear and sinus disease in patients admitted to a regional neurosurgical centre between 1980 and 2004. These data were compared with published material from the same region from 1950–1979.

There was a marked reduction in the mortality rate and the number of intracranial abscesses secondary to chronic ear disease, comparing the two time periods. However, there was little change in the percentage of sinus-related abscesses treated and in their symptoms, signs, abscess location and long term morbidity. Microbiology results showed that streptococcal species predominated as causative organisms, with a high percentage of anaerobic bacteria in otogenic abscesses.

Despite improved outcomes, a high index of suspicion for intracranial complications of ear or sinus disease should be maintained in the presence of appropriate signs and symptoms.

In epistaxis, anterior bleeding points are easily cauterised under direct vision, but those which occur in the posterior nose present a greater challenge. Standard cautery techniques limit simultaneous use of other equipment in the narrow posterior nose.

This article presents a novel device which combines suction, cautery stick and sheath in one single-handed implement for ease of use.

This novel, hand-held device for simultaneous suction and safe cautery of posterior epistaxis is both safe and cost-effective. It enables successful treatment by a single operator and is relatively easy to use by the non-skilled, junior trainee.

To present the historical development of specific instruments used for mastoidectomy and their resulting implications for this surgery.

Compilation of original written documents, trade catalogues and collections of instruments used in mastoid surgery, with a review of the secondary literature on the subject.

The first surgical opening of the mastoid was performed by Petit in 1736 with a trepanation system. More than one and a half centuries later, in 1873, Schwartze codified the operation using chisels and gouges. At the end of the nineteenth century, Macewen introduced the electrical dental burr for mastoid surgery, but it remained largely unrecognised. At the beginning of the 1950s, the systematic use of the microscope in ear surgery allowed generalised use of the drill and improvement of the suction-irrigation system.

Three instrumental periods are recognisable in the history of mastoidectomy: the trepan period, the chisel and gouge period, and the electrical drill period.