External dacryocystorhinostomy has been the treatment for nasolacrimal duct obstruction for more than a century. More recently, nasal endoscopy has allowed this procedure to be carried out endonasally.

The aim of this postal questionnaire study was to compare the health status of patients treated for epiphora by external versus endonasal non-laser dacryocystorhinostomy.

The Glasgow benefit inventory questionnaire, along with an additional, department-based symptomatic questionnaire, was distributed to all patients fitting our criteria.

Satisfactorily completed questionnaires were received from 64 out of 90 patients in the external group and from 30 of 41 patients in the endonasal group. Results indicated positive scores for both groups for all four subscales of the Glasgow benefit inventory. There were no statistically significant differences between results for the external and endonasal procedures. The ocular symptomatology questionnaire results indicated better scores for the external procedure, but this difference did not reach statistical significance.

This study aimed to clarify the significance of cluster of differentiation 9 glycoprotein gene expression in human parotid gland tumours.

We retrospectively analysed immunohistochemical staining for cluster of differentiation 9 glycoprotein in parotid gland tumours.

Cluster of differentiation 9 glycoprotein was consistently detected in the normal parotid gland. Regarding benign parotid gland tumours, cluster of differentiation 9 glycoprotein was present in 13 of 18 pleomorphic adenomas, in all Warthin tumours tested (21/21) and in all cases of basal cell adenoma tested (four of four). In contrast, positive staining for cluster of differentiation 9 glycoprotein was less often observed in malignant parotid tumours. Cluster of differentiation 9 glycoprotein was present in 11 of 14 mucoepidermoid carcinomas, in two of five acinic cell carcinomas and in two of five adenoid cystic carcinomas.

There was a statistically significantly reduced expression of cluster of differentiation 9 glycoprotein in malignant parotid gland tumours, compared with benign parotid gland tumours (p < 0.05). These results suggest that a low level of cluster of differentiation 9 glycoprotein expression in parotid gland tumours may be associated with malignancy.

Ménière's disease is not uncommon, with an incidence in Caucasians of about one in 2000. The incidence peaks in the fifth decade. Cases are usually isolated or sporadic, but in perhaps five per cent other family members are affected. We report here the clinical and genetic characteristics of a comprehensive set of familial Ménière's disease cases from the UK.

Forty-six affected families were studied. All cases were diagnosed using the American Academy of Otolaryngology–Head and Neck Surgery committee on hearing and equilibrium 1995, or more stringent, criteria.

Autosomal dominant inheritance with reduced penetrance was the most likely mode of inheritance overall. Apparent genetic anticipation was observed, but may also be a result of ascertainment bias given the collection strategy. There was also a slight tendency for cases to result from maternal transmission within the families in this set. The family pedigrees are presented, and the authors have also set up a website at which all the pedigrees may be viewed in greater detail.

Haemangiomas do not develop as commonly in the sinonasal cavity, compared with other head and neck sites. The clinical characteristics of sinonasal cavity haemangiomas and the results for endoscopic resection have been addressed in the literature only briefly. Thus, this study aimed to evaluate these points.

A retrospective chart review was undertaken of 22 patients who had undergone endoscopic excision of sinonasal cavity haemangiomas, in order to define clinical characteristics and tumour control rates.

The most common presenting symptom was epistaxis. The most prevalent site was the inferior turbinate (45.5 per cent), followed by the maxillary sinus (18.2 per cent). No recurrence was observed in any patient.

Although past studies have described external approach sinonasal surgery as the mainstay of treatment, our results imply that endoscopic excision of sinonasal haemangiomas yields excellent outcomes in terms of tumour control and safety.

To evaluate the results of endoscopic dacryocystorhinostomy performed to treat acquired nasolacrimal duct obstruction.

Retrospective analysis of the outcome of endoscopic dacryocystorhinostomy performed in the conventional manner (i.e. without power instruments or laser) to treat acquired nasolacrimal duct obstruction.

Outcomes for 300 patients with acquired nasolacrimal duct obstruction were evaluated. Cases with congenital or traumatic blockages were excluded. All the cases were evaluated for nasolacrimal duct blockage by the syringing and regurgitation test. Surgery was performed under local anaesthesia with sedation. Follow up was conducted by syringing and nasal endoscopy, up to one year. Results were compared with published data for endoscopic and external dacryocystorhinostomy.

Outcomes were evaluated subjectively using patient symptoms, syringing results and endoscopic appearance. All cases were symptom-free following endoscopic dacryocystorhinostomy. Revision surgery was performed in 18 cases. Stents were placed in 10 patients, of which two developed granulations. Septoplasty was performed in 25 cases to gain access to the lacrimal sac area.

The results were comparable with published data for endoscopic and external dacryocystorhinostomy.

To investigate whether information about the size of an oral tumour influences the multi-disciplinary team's judgement about the quality of life of head and neck cancer patients.

Using a between-group design, two groups of health care professionals rated a hypothetical patient on 20 outcome variables. The patient description was identical for both groups, except for the tumour size.

Comparison of variable ratings revealed only three significant differences between the groups' predictions and no consistency within conditions, suggesting that the participants held few common assumptions about the impact of tumour size on a range of patient experiences.

The lack of agreement amongst the health care professionals suggests that, where humane judgements are used in treatment decisions for head and neck cancer patients, these may be random and inconsistent. Consequently, patients should have a direct input into treatment decisions, via formalised quality of life data.

After treatment of epistaxis, patients are routinely supplied with an intranasal bactericidal cream containing neomycin. Neomycin cream is effective in preventing recurrent paediatric epistaxis. This study aimed to assess whether there is an increased rate of nasal bacterial infections in adult epistaxis patients.

Between October 2004 and April 2005, nasal swabs were taken from adult patients presenting with epistaxis, and from a control group comprising elective ENT patients.

There were 23 controls and 26 epistaxis patients. Staphylococcus aureus was grown in 21 per cent and 23 per cent, respectively. There was no significant difference in bacterial carriage rates between the epistaxis and control groups.

The epistaxis and control groups demonstrated the same bacterial species and the same proportion of bacterial carriage. Although the majority of bacterial species encountered were sensitive to neomycin, a significant proportion was not. These results do not support the routine use of neomycin in the prevention of recurrent adult epistaxis.

Methicillin-resistant Staphylococcus aureus infections are becoming an increasing problem, but the link with symptomatic sino-nasal infection has not previously been quantified. The aim of this study was to determine the incidence of methicillin-resistant Staphylococcus aureus infection in patients undergoing sino-nasal surgery.

A retrospective study of case notes.

A district general hospital.

One hundred and fifty-one adult patients undergoing in-patient endonasal surgery over a 12-month period were considered for the study.

Swab results from pre-operative screening and from any intra- and post-operative samples of infective mucopus.

One hundred and fifty-one patients undergoing endonasal surgery were included. All patients had pre-operative nasal swabs taken. Twenty-five patients had peri-operative microbiology samples taken. Only one middle meatal swab was found to contain methicillin-resistant Staphylococcus aureus. No patients had methicillin-resistant Staphylococcus aureus detected on pre-operative screening. Haemophilus influenzae was the most common organism detected.

Methicillin-resistant Staphylococcus aureus infection does not represent a significant source of morbidity in our practice.

To describe a new endonasal dacryocystorhinostomy technique and to assess its efficacy.

Prospective, non-randomised, interventional case series.

Patients with primary nasolacrimal duct obstruction were included. A prospective series of 226 consecutive endoscopic transnasal dacryocystorhinostomies performed between January 2003 and December 2006 were entered into the study. Patients who had undergone previous lacrimal surgery were excluded. The surgical technique involved the creation of nasal mucosal and large posterior lacrimal flaps at the medial lacrimal sac wall. The two flaps were placed in close apposition. The technique also involved creation of a large bony ostium.

Success was defined as the resolution of symptoms, or unobstructed lacrimal irrigation and endoscopic visualisation of a patent rhinostomy.

A total of 226 consecutive endoscopic transnasal dacryocystorhinostomy procedures performed between January 2003 and December 2006 were reviewed. The main presentation was with epiphora (95 per cent) and/or mucocele (13 per cent). Septoplasty was performed in 36 per cent of cases at the time of surgery. In 18 per cent of cases, endoscopic sinus surgery was also added to the procedure. The follow-up period ranged from six months to two years. Of the 226 patients, eight were lost to follow up and were thus excluded from the series. The procedure achieved a 92 per cent success rate, in terms of symptom relief and anatomical success.

The described technique of endoscopic endonasal dacryocystorhinostomy had a success rate comparable to that of external dacryocystorhinostomy. The procedure is simple and cost-effective because it does not require sophisticated equipment such as lasers, optical fibres, silicone stents or a microdebrider.

To describe our results with botulinum toxin type A injection for headache in carefully selected patients, and to present the rationale behind this therapy.

Tertiary referral centre.

This article describes a case series of 10 consecutive patients with frontally localised headache, whose pain worsened when pressure was applied at the orbital rim near the supratrochlear nerve. The patients received a local anaesthetic nerve block with Xylocaine 2 per cent at this site. If this reduced the pain, they were then offered treatment with botulinum toxin.

Injection with 12.5 IU of botulinum toxin A into the corrugator supercilii muscle on both sides (a total of 25 IU).

Pain severity scoring by the patients, ranging from zero (no pain) to 10 (severe pain) on a verbal scale.

Following injection, all patients had less pain for approximately two months. This treatment did not appear to have lasting side effects.

Xylocaine injection is a good predictor of the effectiveness of botulinum toxin injection into the corrugator muscle as treatment of frontally localised headache. We hypothesise that this pain is caused by entrapment of the supratrochlearis nerve in the corrugator muscle. Furthermore, we found botulinum toxin injection to be a safe and effective means of achieving pain relief in this patient group.

For various medico-legal and financial reasons, some patients may clinically demonstrate an exaggerated hearing loss that varies in degree, nature and laterality. The purpose of this study was to evaluate whether multi-channel auditory steady-state response measurement can be used as an objective test of auditory thresholds in adults with sensorineural hearing loss.

This was a prospective, comparative, experimental research design study conducted in an academic medical centre. From January to June 2007, 142 subjects (284 ears) with varying degrees of sensorineural hearing loss were included. Four commonly used frequencies (500, 1000, 2000 and 4000 Hz) were evaluated. Both pure tone thresholds and multi-channel auditory steady-state response thresholds were obtained for each ear in all subjects. The correlation of auditory steady-state response thresholds and pure tone thresholds was assessed. The time taken for multi-channel auditory steady-state response testing was also recorded.

Results for multi-channel auditory steady-state response thresholds and pure tone thresholds were compared for each test frequency. A difference of less than 15 dB was found in 71 per cent of patients, while a difference of less than 20 dB was found in 83 per cent. Correlation between auditory steady-state response thresholds and pure tone thresholds, expressed as the correlation coefficient (r), was 0.89, 0.95, 0.96 and 0.97 at 500, 1000, 2000 and 4000 Hz, respectively. The strength of the relationship between auditory steady-state response thresholds and pure tone thresholds increased with increasing frequency and increasing degree of hearing loss. The recorded auditory steady-state response thresholds were used to calculate regression lines predicting pure tone threshold results. The mean estimated pure tone thresholds calculated from these regression lines were all within 10 dB of the actual recorded pure tone thresholds. The average multi-channel auditory steady-state response test duration was 42 minutes per patient.

Measurement of multi-channel auditory steady-state response could be a powerful, convenient electro-physiological examination with which to objectively certify clinical hearing impairment in adults.

To assess the technical success, clinical outcomes and complications of radiologically guided balloon dilatation of benign strictures developing after treatment for head and neck cancer.

Forty-six balloon dilatations were performed in 20 patients. All dilatations were performed over a guidewire.

Technical success was 100 per cent. Fifteen of the 20 patients demonstrated clinical improvement in dysphagia scores. Improvement in dysphagia was temporary in all patients (median 102 days), with multiple dilatations usually required (total dilatations ranged from one to seven). Immediate complications were encountered in six of the 46 (13 per cent) dilatations and were all minor. Late complications occurred after two procedures (4 per cent): localised perforation (later complicated by secondary infection) and recurrence of a previous, small, pharyngo-cutaneous fistula.

Radiologically guided balloon dilatation is straightforward to perform and is well tolerated, but there is a small risk of perforation. Relief of symptoms is likely to be temporary, requiring multiple subsequent dilatations. A minority of patients will obtain no symptomatic relief.

To analyse the correlation between visual fixation suppression test results and the occurrence of post-operative vertigo in patients receiving a cochlear implant, and to compare this with other possible risk factors.

In a prospective study setting, caloric vestibular responses, visual fixation suppression and subjective vertigo symptoms were assessed in 59 adult patients undergoing cochlear implantation. These parameters were compared in patients with post-operative vertigo versus vertigo-free patients.

Vertigo symptoms were reported by 49 per cent of patients. Thirty-nine per cent of the patients had a decrease in caloric response on the implanted side. There was no statistically significant difference between the two patient groups regarding canal paresis, age, sex, implanted electrode type, implant side, surgeon, cause of deafness, petrous bone computed tomography findings and incidence of pre-operative vertigo. Patients with post-operative vertigo had a significantly greater prevalence of insufficient visual fixation suppression. All patients who suffered long-term post-operative vertigo had insufficient visual fixation suppression.

Pre-operative impaired visual fixation suppression is a major risk factor for the occurrence of vertigo after cochlear implantation.

To ascertain the sensitivity and specificity of clinical diagnosis of obstructive sleep apnoea in children, and to determine if a published clinical algorithm identifies those at high risk of post-adenotonsillectomy complications.

Sixty-seven children aged three to eight years underwent clinical assessment and overnight polysomnography.

Polysomnography detected a significant apnoea–hypopnoea index (i.e. ≥5, indicating significant obstructive sleep apnoea) in 13 (43 per cent) children with a clinical diagnosis of obstructive sleep apnoea and in six (19 per cent) children with no such diagnosis. The sensitivity of clinical assessment was 68.4 per cent and the specificity 59.5 per cent. The post-operative risk algorithm failed to identify any high risk children, although in actuality seven had severe obstructive sleep apnoea confirmed by polysomnography.

This study of two English centres confirms that the clinical diagnostic process for obstructive sleep apnoea is reasonably insensitive and has low specificity. The studied algorithm discriminated poorly between children with and without severe obstructive sleep apnoea. Realistic diagnostic screening guidelines for paediatric sleep apnoea are overdue in the UK, where access to polysomnography is limited.

Sleep apnoea, whether obstructive or central, is usually diagnosed by polysomnography. A simpler tool for screening high risk populations may be of value.

We compared a portable device using nasal pressure cannulae and a high-sensitivity pressure sensor (the ApneaLink®) with our standard polysomnography technique for diagnosing sleep apnoea (using the Embletta® device), in 67 patients being investigated for possible sleep apnoea. The patients' average age was 52.6, 79 per cent were male, the mean body mass index was 32.3, and the mean Epworth sleepiness score was 13.0.

Twenty-five patients (45 per cent) were identified as having an apnoea–hypopnoea index of >15, as measured by the Embletta. The mean (standard deviation) apnoea–hypopnoea index was 21.5 ± 23.0 as measured by the Embletta and 24.3 ± 26.2 as measured by the ApneaLink. The sensitivity of the ApneaLink for an apnoea–hypopnoea index cut-off point of 15 was 92 per cent and the specificity was 96.7 per cent. The negative predictive value of the ApneaLink for an apnoea–hypopnoea index of ≤15 was 94 per cent.

The ApneaLink is a useful tool for screening patients thought to have possible sleep apnoea, and for selecting patients for definitive diagnostic testing.

To determine the causes of delay in diagnosis and treatment of Indian patients with vestibular schwannomas.

In a prospective study from 2003 to 2005, 50 patients with a confirmed diagnosis of vestibular schwannoma were interviewed to determine the causes for (1) the delay between the patient noting the initial symptom and the definitive diagnosis, and (2) the reasons for delayed diagnosis.

In 90 per cent of patients, the initial symptom was either hearing loss (62 per cent), vertigo (24 per cent) or tinnitus (4 per cent). However, most patients had been diagnosed and had presented for surgery only after neurological symptoms had became apparent. The delay between the initial medical consultation and the final diagnosis ranged from one month to 204 months (mean ± standard deviation, 32.2 ± 38.9 months). After the patient had noted symptoms, the diagnosis of vestibular schwannoma was delayed due to doctor-related causes in 80 per cent of cases, and due to patient-related causes in 20 per cent. Delay following diagnosis was minimal.

Delay in the diagnosis of vestibular schwannoma in Indian patients is due to both doctor- and patient-related factors.

In vivo laser scanning confocal microscopy is a relatively new, non-invasive method for assessment of oral cavity epithelia. The penetration depth of approximately 200–400 µm allows visualisation of fungiform papillae and their taste buds.

This paper describes the technique of in vivo volumetry of human taste buds. Confocal laser scanning microscopy used a diode laser at 670 nm for illumination. Digital laser scanning confocal microscopy equipment consisted of the Heidelberg Retina Tomograph HRTII and the Rostock Cornea Module. Volume scans of fungiform papillae were used for three-dimensional reconstruction of the taste bud.

This technique supplied information on taste bud structure and enabled measurement and calculation of taste bud volume. Volumetric data from a 23-year-old man over a nine-day period showed only a small deviation in values. After three to four weeks, phenomenological changes in taste bud structures were found (i.e. a significant increase in volume, followed by disappearance of the taste bud and appearance of a new taste bud).

The data obtained indicate the potential application of this non-invasive imaging modality: to evaluate variation of taste bud volume in human fungiform papillae with ageing; to study the effects of chorda tympani nerve transection on taste bud volume; and to demonstrate recovery of taste buds in patients with a severed chorda tympani nerve who show recovery of gustatory sensibility after surgery.

To improve case selection for near-total laryngectomy by identifying the causes of poor oncological and functional outcomes.

Analysis of prospectively accrued data for 28 consecutive cases of near-total laryngectomy undertaken between 1996 and 2005 at a tertiary care centre. We analysed the impact of tumour extent and location, patient physiological status, and surgical technique on disease-free survival and on functional outcome.

Patients' average four-year Kaplan–Meier disease-free survival was 74 per cent (95 per cent confidence intervals, 46–89 per cent). Eighty-two per cent of patients had good to excellent functional outcomes. Pre-operative tumour extension to the ipsilateral arytenoid significantly compromised disease-free survival (patients with this development had a two-year survival of 40 per cent; p = 0.001). Internal communicating fistula formation (i.e. a fistula between the neopharynx and myomucosal shunt lumens) occurred in five of 28 cases and was uniformly associated with a poor functional outcome (i.e. lack of phonation with or without aspiration). Fistula formation was significantly more likely in cases with tumour involving the ipsilateral arytenoid and the ipsilateral subglottis.

Significant disparity exists for the functional outcome of near-total laryngectomy in patients who develop post-surgical internal fistula, compared with those with uneventful healing. Tumour involvement of the ipsilateral arytenoid compromises the oncological and functional results. Tumour extension to the subglottis may compromise functional outcome. Near-total laryngectomy should be avoided in cases with ipsilateral arytenoid involvement, and undertaken with caution in cases with subglottic extension.