To evaluate the role of vestibular assessment in the management of the dizzy patient.

A retrospective review of case notes and vestibular assessment reports of 100 consecutive patients referred for vestibular assessment.

Sixty of the 100 patients had an abnormal vestibular assessment. Eleven patients had benign paroxysmal positional vertigo as the sole diagnosis, of whom nine had not had a Dix–Hallpike manoeuvre performed before referral. Of patients referred for vestibular rehabilitation, 76 per cent had an abnormal electrophysiological assessment. After vestibular assessment, 35 patients were discharged with no further follow-up appointments in the ENT department.

All patients should have a Dix–Hallpike manoeuvre performed prior to referral for vestibular assessment. The majority of our patients undergoing vestibular rehabilitation had abnormal test results, although a significant number did not. Prior to referral, it is worth considering the implication of a ‘normal’ and ‘abnormal’ result for the management of the patient. Careful consideration should be given to the development of dedicated dizziness clinics run by practitioners with a specialist interest in balance disorders, in order to ensure appropriate requests for vestibular assessment.

Interferon-γ has been reported to have an immunoregulatory role in otitis media with effusion. However, such a role remains to be determined in acute suppurative otitis media.

To determine the levels of interferon-γ in middle-ear secretion in children with acute suppurative otitis media, and to determine the significance of interferon-γ to the nature of otorrhoea and the outcome of otitis media.

Prospective, longitudinal follow up of patients selected from community and tertiary health centres.

We selected children with acute suppurative otitis media, diagnosed as otorrhoea of less than three months' duration. Middle-ear secretions were collected by pipetting and stored at −80°C. Interferon-γ was assayed using enzyme-linked immunosorbent assay. The patients were treated and followed up for nine to 12 months, to separate those with resolved acute suppurative otitis media from those with chronic suppurative otitis media.

The study initially included 358 cases of acute suppurative otitis media. Nine-month follow up was achieved in 304 patients (85 per cent). Of these patients, acute suppurative otitis media resolved in 187 (61 per cent), while chronic suppurative otitis media was evident in 117 (39 per cent). The children with completed follow up comprised 173 boys and 131 girls, aged between four months and nine years (mean age 6.6 years; standard deviation 1.32). These children had purulent otorrhoea in 171 cases (56 per cent) and mucoid otorrhoea in 133 cases (44 per cent). The children's middle-ear secretion interferon-γ concentrations ranged from 12 to 126 pg/ml. The mean middle-ear secretion interferon-γ concentration was 27.2 pg/ml (standard deviation 8.8) in patients whose acute suppurative otitis media resolved, and 73.1 pg/ml (standard deviation 9.5) in those progressing to chronic suppurative otitis media. In children with purulent otitis media, the mean middle-ear secretion interferon-γ concentration was 43.5 pg/ml (standard deviation 15.6); in those with mucoid otitis media, it was 74.3 pg/ml (standard deviation 19.1). Univariate analysis revealed significant differences in middle-ear secretion interferon-γ concentration, comparing resolved acute suppurative otitis media and chronic suppurative otitis media cases (p = 0.00), and comparing purulent and mucoid otitis media cases (p = 0.00). Pearson correlation testing revealed significant inverse correlation between interferon-γ concentration and middle-ear secretion immunoglobulin G concentration (p = 0.01), immunoglobulin E concentration (p = 0.03) and immunoglobulin A concentration (p = 0.00).

A high concentration of interferon-γ in middle-ear secretions promotes chronicity of suppurative otitis media. Further research in this area may lead to the development of agents which assist the control of suppurative otitis media chronicity.

This study aimed to compare an experienced ENT treatment room nurse's ability to assess nasal injuries with that of junior doctors.

One hundred consecutive patients with nasal injuries were assessed prospectively in two phases, followed by a telephone survey.

Comparison of nasal injury assessment, advice, and outcomes regarding cosmesis, airway obstruction and patient satisfaction.

In the first phase, there was almost perfect agreement between doctor and nurse assessments regarding the management of nasal fractures (p < 0.0001). There was no deterioration in outcomes in the nurse assessment only patient group with regards to cosmesis and airway obstruction. Ninety-four per cent of patients were satisfied with nurse-only assessment.

Our study showed that an experienced treatment room nurse was as effective as experienced junior doctors in assessing and advising patients with nasal injuries. Following this study, the nurse involved began to independently assess patients with nasal injuries attending the unit.

Double-probe, 24-hour pH monitoring remains the ‘gold standard’ for the diagnosis of laryngopharyngeal reflux disease, even though there is no consensus on how to interpret the data collected.

Tetra-probe, 24-hour pH monitoring was performed in 56 patients with suspected laryngopharyngeal reflux, in order to investigate patterns of laryngopharyngeal and gastroesophageal reflux.

The number of reflux episodes and the total and percentage time periods spent with pH < 4.0 were correlated with the distance of the probe from the lower oesophageal sphincter. The number of reflux episodes and the total and percentage time periods with pH < 4.0 were greater when patients were upright (i.e. during the daytime). There were few laryngopharyngeal reflux events recorded for pH levels of <4.0; however, there were a significant number of laryngopharyngeal reflux events recorded for pH levels of <5.0, a level capable of causing laryngopharyngeal reflux disease. When a pH level of <5.0 was used, the number, total time and percentage time of laryngopharyngeal reflux episodes was greater during the supine period (i.e. during sleeping) in a quarter of the cases, compared with results when a pH of <4.0 was used.

It is valid to use a pH level of 5.0 as indicative of laryngopharyngeal reflux in the hypopharynx.

Young's syndrome describes a combination of male infertility, azoospermia, bronchiectasis and sinusitis. Although Young's syndrome is a well accepted disorder within the realms of infertility medicine, it is also accepted as being a potential cause of sino-nasal disease which is rarely seen by otolaryngologists. However, the significance of the sinus component within this triad is not fully understood. To gain further insight into the relationship of sinusitis with Young's syndrome, we reviewed all of the currently available published literature.

Within the reviewed literature, the diagnosis of sinusitis in Young's syndrome was crude and poorly defined; there was little emphasis on sinus disease in most publications.

The prevalence of Young's syndrome is reported to be declining, and the level of evidence regarding sinus disease within this syndrome is limited to case series only. There is, in fact, little evidence to support Young's syndrome being a significant aetiological factor for sinus disease, nor indeed to support the existence of Young's syndrome as an entity in its own right. The only documented aetiological factor is mercury exposure in childhood, an event that is seldom currently encountered; this would support our theory of the extinction of the condition. As an incidental finding, we found that the term Young's syndrome refers to two different medical conditions.

The paranasal sinuses, comprising the frontal, maxillary, ethmoid and sphenoid sinuses, have caused consternation and debate over their true function over the course of nearly two millennia. This review aims to define the current evidence for the role of the paranasal sinuses, and to attempt to propose an answer to the question ‘why do we have paranasal sinuses?’

A literature review was conducted, searching Medline (1966–2007), Embase (1988–2007), the Cochrane Library and Ovid (1966–2007). Combinations of the following search terms were used: ‘paranasal sinuses’, ‘physiology’, ‘anatomy’, ‘function’, ‘evolution’ and ‘rhinology’. Any relevant references were cascaded to increase detection of pertinent information. The current, tenable theories identified in the literature review are discussed and the evidence for them critically analysed.

The current, tenable theories are described.

The paranasal sinuses may act simply to improve nasal function; certainly, it has been demonstrated that they may act as an adjunct in the production of nitric oxide and in aiding the immune defences of the nasal cavity. However, there is a distinction between utility and evolutionary origin. It may still be that the sinuses arose as an aid to facial growth and architecture, or persist as residual remnants of an evolutionary structure with an as yet unknown purpose, and in doing so have found an additional role as an adjunct to the nasal cavity.

Conscious and deceptive exaggeration of hearing loss is termed pseudohypacusis. Even though the Stenger test has been used in the management of pseudohypacusis for almost a century, its sensitivity, specificity and predictive values for unilateral pseudohypacusis have not previously been reported, to our best knowledge. We investigated the efficiency of the Stenger test in detecting unilateral pseudohypacusis, accepting auditory brainstem response testing as the ‘gold standard’.

Candidates with questionable profound or total hearing loss were enrolled in the study. Pure tone audiometry, speech and tonal Stenger tests, and click test auditory brainstem response measurement were performed. Accepting auditory brainstem response testing as the gold standard, the sensitivity, specificity and predictive values of the Stenger test for unilateral, profound pseudohypacusis were assessed.

Two hundred military candidates were enrolled in the study. The sensitivity and specificity of the Stenger test in verifying unilateral, profound hearing loss were 99.4 and 70 per cent, respectively. The positive and negative predictive values of the test were 87.5 and 98.4 per cent, respectively.

The Stenger test is widely used for the evaluation of unilateral or asymmetrical pseudohypacusis. In our opinion, it is a powerfully reliable test. More difficult cases require objective electrophysiological testing to verify functional hearing loss and to exclude specific diagnoses that may imitate pseudohypacusis.

The term septal body refers to a thickened area of the nasal septum which is located superior to the inferior turbinate and anterior to the middle turbinate. Despite its important role in changing nasal airflow resistance, it has received little attention. Clinically, a well developed septal body may be misdiagnosed as high septal deviation.

The aim of the present study was to reassess the histological characteristics of the septal body mucosa and the morphometric differences between it and the adjacent septal mucosa. This information was then used to determine the exact location and surface area of the septal body.

The study was performed on 30 cadaveric specimens (60 sides). Serial numbered sections of the whole septal mucosa were stained with haematoxylin and eosin as well as periodic acid Schiff – Alcian blue. Morphometric analysis was performed to determine the histological differences between the septal body mucosa, the anterior septal mucosa and the inferior septal mucosa. The precise boundaries of the septal body area were then defined in a manner similar to the Mohs micrographic surgical technique.

The histological characteristics of the septal body mucosa included thick (more than 60 µm), pseudostratified, ciliated respiratory epithelium with goblet cells, abundant seromucinous glands and many blood sinusoids. Morphometric analysis showed that the septal body mucosa had thicker epithelium and more glandular acini and blood sinusoids than the rest of the septal mucosa. Mapping of the septal body area showed that its anterior end was 2.2 ± 0.3 cm (mean ± standard deviation) behind the caudal edge of the septal cartilage, and its inferior border was 1.1 ± 0.2 cm above the floor of the nose. The mean horizontal diameter of the septal body was 2.0 ± 0.15 cm, and the mean vertical diameter was 1.5 ± 0.11 cm.

The present study determined the morphometric characteristics of the septal body as well as its location and surface area. The intimate relationship of the septal body to the internal nasal valve and the histological characteristics of its mucosa should stimulate research into its potential role in modifying nasal airflow pattern and resistance, and its role in changing the humidity and temperature of the inspiratory air stream.

To evaluate the treatment of intracranial abscess of otogenic origin, and to study the outcome measures of single stage treatment of the otogenic focus and drainage of intracranial abscess via a transmastoid approach.

Retrospective case review.

Dr Balabhai Nanavati Hospital and Medical Research Centre, Mumbai, India, an academic tertiary referral centre, and Shri H Bhagwati Municipal General Hospital, Mumbai, India, an academic secondary referral centre.

Seventy-three patients with intracranial abscess secondary to otogenic pathology, confirmed by computed tomographic scanning.

Single stage treatment of the ear pathology and drainage of intracranial abscess via a transmastoid approach, performed by the senior author (KPM).

Of the 73 patients, 12 were lost to follow up and were excluded from the study. Outcomes for the remaining 61 patients were known, and these patients were followed up for at least two years. Adults were more commonly affected by otogenic intracranial abscess than children, with a male preponderance. Otogenic intracranial abscess was associated with both cholesteatomatous (41 per cent) and non-cholesteatomatous ears (59 per cent). All cases were treated with transmastoid drainage of the intracranial abscess and canal wall up or down tympanomastoidectomy, depending on the ear pathology. Two cases developed post-operative cerebrospinal fluid leakage (3 per cent), and another two cases developed meningitis (3 per cent). Five patients had recurrent abscess; two of these patients (3 per cent) died but were included in the study. Three patients had residual abscess, improved with additional management.

In this series, the low morbidity and mortality rate, combined with a shorter hospital stay, suggest that single stage, transmastoid drainage of intracranial abscess and concurrent treatment of the otogenic pathology is an effective treatment for otogenic intracranial abscess.

We evaluated the results of mobile, one stage, bilateral ear surgery conducted in Greenland, where chronic otitis media with and without suppuration is prevalent. The study aimed to increase the number of operations conducted and to reduce the cost of ear surgery in remote areas.

The study was longitudinal and prospective, with a two-year follow up. Seventeen East Greenlandic patients with bilateral chronic suppurative otitis media or chronic otitis media were selected. Their median age was 16 years; 53 per cent were female and 47 per cent male. Hearing was assessed using median air conduction pure tone average gain, and the ‘take rate’ (i.e. the percentage of total ears with a closed perforation) was evaluated.

All patients attended for follow up. Eighty-two per cent had at least one perforation closed, and the overall take rate was 65 per cent of the 34 ears. The median air conduction pure tone average gain after two years was 18 dB and 13 dB for the right and left ears, respectively. Fourteen patients (82 per cent) obtained an air conduction pure tone average hearing level of ≤25 dB in at least one ear. In total, 71 per cent of the patients were satisfied. There were no hearing hazards.

The results of mobile, one stage, bilateral ear surgery conducted in Greenland for long-lasting chronic suppurative otitis media and chronic otitis media were acceptable and safe, and more ears underwent surgery at reduced cost compared with unilateral ear surgery.

Patients suspected of having cervical tuberculous lymphadenitis are diagnosed using investigations such as fine needle aspiration cytology and the polymerase chain reaction for Mycobacterium tuberculosis. However, these investigations are intended for primary tuberculosis infection. The majority of cervical tuberculous lymphadenitis cases in the elderly are thought to be caused by reactivation.

The aims of this study were (1) to examine the efficacy of fine needle aspiration cytology, polymerase chain reaction and blood tests in the diagnosis of cervical tuberculous lymphadenitis caused by reactivation, and (2) to clarify any differences when compared with primarily infected cervical tuberculous lymphadenitis cases.

Thirty-three elderly patients with neck lumps underwent excisional biopsy from 2003 to 2008. The efficacy of fine needle aspiration cytology was examined by comparing the results of excisional biopsy with those of fine needle aspiration cytology performed at the initial medical examination for cases of suspected tuberculous disease. Furthermore, the leucocyte count and C-reactive protein concentration were compared for cases of cervical tuberculous lymphadenitis versus cases of malignant lymphoma.

Although nine cases were diagnosed with cervical tuberculous lymphadenitis using excisional biopsy, only one of these had been suspected based on fine needle aspiration cytology results. Three cases with tuberculous lymphadenitis were suspected of having malignant lymphoma on initial examination. There was no significant difference in the leucocyte count and C-reactive protein concentration, comparing cases of tuberculous lymphadenitis versus malignant lymphoma.

Unlike the primary infection often seen in endemic areas, the diagnosis of early stage tuberculous lymphadenitis of the swelling type caused by reactivation in elderly people is difficult to confirm unless excisional biopsy is performed. In elderly patients with neck lumps, cervical tuberculous lymphadenitis should be included in the differential diagnosis.

To evaluate the effectiveness of hyperbaric oxygen therapy in the management of sudden hearing loss.

Patients with sudden hearing loss were divided into study and control groups. The 36 patients in the study group were treated with hyperbaric oxygen therapy in addition to standard medical therapy, whereas the 21 patients in the control group were treated with only standard medical therapy.

Both groups were treated with standard therapy, comprising prednisolone starting at a dose of 1 mg/kg and reducing over three weeks. Patients in the study group received hyperbaric oxygen therapy in addition to standard drug therapy.

Success rates were 78.95 per cent in the study group and 71.30 per cent in the control group. However, this difference was not statistically significant (p > 0.05).

Considering the cost of hyperbaric oxygen therapy and its inconvenience to patients, this treatment should only be considered in patients suffering sudden hearing loss if there are contraindications to standard medical treatment.

This paper reviews our experience of ossicular chain injuries following head trauma treated at Groote Schuur Hospital, Cape Town, South Africa.

We performed a retrospective chart review of all patients with a history of head trauma and a conductive hearing loss who had undergone exploratory tympanotomy. Sixteen patients were included in the study.

Injury was most common at the incudostapedial joint (63 per cent). Disarticulations of the icudostapedial joint were treated with cartilage interposition in all cases. Audiography showed an improvement in 12 of the patients, with an average improvement of 35 dB.

We discuss the various options available to the otologist to repair ossicular disruptions after trauma. In this series, cartilage autografts were used in most incudostapedial joint injuries, with excellent closure of the air–bone gap.

Cartilage interposition was a very successful method of repairing incudostapedial joint dislocation in this series, at short term follow up.

To assess the efficacy of rehabilitation for dizzy patients after recent acute vestibular disturbance.

Forty patients recently hospitalised for an acute episode of rotational vertigo which lasted days were randomly divided into two groups. The first group (20 patients; group R) underwent active rehabilitation, while the second group (20 patients; group C) were told only to ‘perform their daily activities’. Group R subjects underwent a total of 10 sessions of rehabilitation, including exercises on a stabilometric platform, point de mire and a series of five exercises repeated five times daily. All patients performed static stabilometry (posturography), undertook the dynamic gait index test, and completed a dizziness handicap questionnaire and a visual analogue scale for anxiety, at baseline and on completion.

At 25 days, the rehabilitated patients obtained better results for all recorded outcomes, compared with the control group. The greatest difference in the rehabilitated subjects, compared with the control group, was for the dynamic gait index test; however, this difference was not statistically significant. The visual analogue scale anxiety score was statistically significantly more reduced in rehabilitated patients compared with control patients. Control patients maintained a higher visual dependence for postural control.

These results would appear to support the effectiveness of a supervised exercise programme for patients following acute onset of vestibular disturbance. A correlation was found in both groups between dynamic gait index results and anxiety. In our experience, a rehabilitation programme seems to reduce dependence on visual cues for postural control.

To describe a series of 40 culture-proven, Streptococcus suis infected patients, focusing on route of entry and on hearing and vestibular dysfunction.

Retrospective study of patient records in a tertiary care hospital in northern Thailand, 2003–2007.

The majority (75 per cent) of cases were men with heavy drinking habits. A past history of the consumption of raw pork and/or pig's blood was found in 62.5 per cent of cases, whereas contact with swine products was found in 25 per cent. Thirty patients presented with sepsis, 19 with meningitis and 10 with infective endocarditis. The overall mortality rate was 20 per cent. After a mean follow up of 17 months, 73 per cent of the surviving meningitis cases had persistent sensorineural hearing loss and 50 per cent demonstrated vestibular impairment. In one patient, roentgenographic studies of the temporal bone were compatible with labyrinthitis ossificans.

Permanent hearing loss and vestibular impairment occur frequently in persons surviving meningitis caused by Streptococcus suis.

To evaluate the hearing results of a large series of primary stapedotomies, according to American Academy of Otolaryngology, Head and Neck Surgery guidelines and Amsterdam hearing evaluation plots.

Retrospective chart review.

The charts for 1369 consecutive stapedotomy cases were reviewed; 1145 cases of primary stapedotomy were included. Raw data from the audiometric database were evaluated using Amsterdam hearing evaluation plots. The effect on outcomes of using different audiological parameters was analysed.

A significant improvement was demonstrated in mean post-operative air conduction and speech reception thresholds, with no change in bone conduction. Air–bone gap closure of 10 dB or more was achieved in 82 per cent of cases. A ‘dead ear’ occurred in one patient (0.1 per cent).

This study reports the largest series of primary stapedotomies evaluated with Amsterdam hearing evaluation plots. This method enables visual identification of successful and unfavourable results, providing more accurate and detailed presentation of surgical outcomes.

The aim of this study was to investigate the effect of local application of platelet-rich plasma to perforated rat tympanic membranes, in terms of healing time and histopathological outcome.

Eighty-eight tympanic membranes of 44 rats were given a standard 3 mm perforation, and platelet-rich plasma was applied to the right tympanic membrane perforations. The left tympanic membranes were left to heal spontaneously, as controls. The 44 rats were divided into two groups. In group one, comprising 20 rats, daily otomicroscopic examination of the tympanic membrane perforations was performed. The 24 rats in group two were subdivided into four subgroups of six rats each; these subgroups were sacrificed sequentially on days three, seven, 14 and 28 for histopathological examination, regardless of tympanic membrane healing stage.

In group one, the mean tympanic membrane healing times for tympanic membrane perforations receiving platelet-rich plasma and controls were respectively 10.2 ± 2.1 and 13.0 ± 2.9 days (mean ± standard deviation). This difference was statistically significant (p < 0.001). In group two, histopathological evaluation of tympanic membrane perforation healing at days three, seven, 14 and 28 did not reveal any statistically significant difference, individually or within the four groups as a whole.

These findings suggest that earlier healing of tympanic membrane perforations occurred in the platelet-rich plasma group compared with the control group. These findings suggest that platelet-rich plasma is effective in accelerating tympanic membrane perforation healing, and that it may be effective in human subjects, particularly as it is an autologous material.

The Avon Area Health Authority was a first-phase site for introduction of universal newborn screening in the UK. The aims of this study were: to review the programme's results to date; to assess the impact screening would have on other services (e.g. the cochlear implant programme); and to assess the longer term outcome for children identified by the screening programme.

All children identified by the Avon universal newborn hearing screening programme between April 2002 and July 2006.

Fifty-four children with a bilateral hearing impairment of worse than 40 dBHL were identified from a screened population of approximately 44 000. Nine of these children were put forward for cochlear implantation, and seven had been implanted at the time of writing. Thirteen of these children were identified with possible auditory neuropathy or dys-synchrony. All the newborn hearing screening programme criteria assessed were met.

The screening programme was effective. Some areas may need review in order to optimise patient care.

The paraglottic space and cricoid area of the larynx are made up of loose, areolar tissue composed of loose elastic and collagenous fibres and adipose tissue. They contain the main blood vessels of the larynx. We examined the correlation between the histopathological extension of glottic carcinoma into the paraglottic space or cricoid area and the development of cervical lymph node metastasis.

We reviewed the medical charts of 45 patients (44 men and one woman) who had undergone total laryngectomy for squamous cell carcinoma of the glottis between 1991 and 2003.

Macroscopic and microscopic study of the removed larynges of the same patients was performed, and the histopathological evidence for invasion of the paraglottic space or cricoid area was analysed.

Eight of the 24 patients (33 per cent) with invasion of the paraglottic space or cricoid area had cervical lymph node metastasis. In contrast, only one of the 21 patients (5 per cent) without any evidence of invasion of either space had lymph node metastasis. This difference was statistically significant (p < 0.05). In the 36 patients free of cervical lymph node metastasis, recurrence in the neck occurred in six (38 per cent) of the 16 patients with paraglottic space or cricoid area invasion, but in only one (5 per cent) of the 20 patients without paraglottic space or cricoid area invasion (p < 0.05).

In patients with glottic carcinoma, invasion of cancer into the paraglottic space or cricoid area is an important prognostic factor for the development of cervical lymph node metastasis.