Aim: To evaluate the criteria for diagnosing allergic fungal sinusitis and to maintain permanent drainage and ventilation, while preserving the integrity of mucosa. Methods: This is a prospective study of 251 patients with chronic rhinosinusitis with or without polyposis, of whom 199 were treated surgically. Mucus sample collection, nasal secretion culture, surgical specimen handling and histological evaluation of surgical specimens are described. The management included wide local endoscopic sinus debridement, adequate sinus aeration, post-operative use of steroids and antifungal therapy. Results: Fungal cultures of nasal secretions were positive in 201 (80.01 per cent) of 251 patients. Of the 199 surgical cases, fungal elements were found in 156 histological specimens (62.1 per cent). Allergic mucin was found in 182 patients (91.45 per cent). Nasal obstruction and proptosis were the commonest presentations. All pre-operative versus post-operative changes in AFS-associated complaints reached statistical significance of p < 0.001. The ethmoid sinus was commonly involved with adjacent lamina papyracea exhibiting demineralization in 26.6 per cent of cases. Intracranial extension was seen in 15 cases. Recurrence was noted in 11 cases. Conclusion: Comprehensive treatment with endoscopic sinus surgery, steroids and antifungal therapy is needed. AFS is readily recurrent. Long-term follow up is important.

A significant number of patients requiring septal surgery are still undergoing in-patient procedures at a time when pressures on in-patient beds are increasing.

A retrospective audit of 109 patient case notes was performed to assess the potential for day-case surgery amongst patients undergoing septal surgery in the ENT department at Leicester Royal Infirmary. The other aims of the audit were to assess the overall complication rates, because these have implications for day-case surgical patients, and to see which patients should be selected.

Overall, the study group had a haemorrhage rate of six per cent and a potential for 92 per cent of cases to be performed as day-case procedures.

Day-case septal surgery, if utilized appropriately, has great potential in reducing the pressure on inpatient beds.

Objective: The purpose of this study was to determine the susceptibility of organisms causing otitis externa (OE) to the essential oil of Melaleuca alternifolia, or tea tree oil (TTO).

Methods: Fifty-seven swabs were taken from the ears of 52 patients with OE for culture and sensitivity. A broth microdilution method was used to determine the minimum inhibitory concentration (MIC) of TTO for each organism.

Results: In 51 per cent of the swabs taken, pathogenic organisms were cultured. Of these cultures 71 per cent, both bacteria and yeast, were susceptible to TTO 2 per cent or less. The only organism showing resistance to TTO was Pseudomonas aeruginosa; however 25 per cent of these bacteria were sensitive.

Conclusion: Tea tree oil may have a role to play in the treatment of OE. However, more work needs to be done to enhance the anti-pseudomonal effect and to assess ototoxicity.

Extensive functional endoscopic sinus surgery (FESS) was assessed retrospectively from the viewpoint of out-patients on the basis of their responses to a postal questionnaire, particularly in the Tokyo metropolitan area. Seventeen patients were included in this study (six females and11 males) with an age range of 22–70 years. All the patients had at least ethmoid sinusitis. Additionally, some patients had maxillary or sphenoid sinusitis or polyps obstructing the nasal cavities. The average operation time and blood loss were 36 minutes and 31 ml, respectively. Four patients had to travel more than one hour to reach home. All of them used the train for travelling to and from the hospital. ’Doctors’ advice’ was the most common reason for the decision to undergo this ambulatory surgery. Nine (53 per cent) had some unexpected problems post-operatively. The establishment of a care pathway may improve the outcome of extensive FESS on an out-patient basis.

The aim of the present study is to evaluate the effect of swallowing type (dry versus wet) on the outcome of a nine-step inflation/deflation tympanometric Eustachian tubefunction (ETF) test in healthy adults.

Fourteen normal healthy volunteers, between 19 and 28 years of age, were included in the study. The nine-step test was performed in two different test procedures: (1) test with dry swallows (dry test procedure) and (2) test with liquid swallows (wet test procedure). If the equilibration of middle-ear (ME) pressure was successful in all the steps of the nine-step test, ETF was considered ‘Good’. Otherwise, the test was considered ‘Poor’, and the test was repeated at a second session.

In the dry test procedure, ETF was ‘Good’ in 21 ears at the first session and in 24 ears after the second session (p > 0.05). However, in the wet test procedure, ETF was ‘Good’ in 13 ears at the first session and in 21 ears after the second session (p < 0.05).

At the first session, ETF was ’Good’ in 21 and 13 ears in the dry and wet test procedures, respectively. The difference was statistically significant (p < 0.05). However, after the second session, the overall number of ears with ‘Good’ tubal function was almost the same in both test procedures (24 ears at dry test procedures versus 21 ears at wet test procedures;p > 0.05).

Dry swallowing seems to be more effective for the equilibration of ME pressure. Thus, a single-session dependent evaluation of ETF may be efficient for the dry test procedure of the nine-step test. Swallowing with water may be easier for subjects, but a repetition of the test at a second session may be necessary when the test result is ‘Poor’.

This was a retrospective study of patients who did or did not receive post-operative radiotherapy for squamous cell carcinoma of the larynx.

The rates of local and regional recurrences, distant metastases and second primaries were evaluated in 236 patients who received radiotherapy following surgery. These rates were evaluated and compared with those from 294 patients treated with surgery alone.

Multivariate analysis of irradiated patients revealed that local and regional recurrences were determined independently by tumour (T) and pathologic node (pN) stages (p < 0.05). The distant metastasis rate significantly depended on N stage (p < 0.05). Multiple primary tumours were not significantly affected by any of the factors studied (p > 0.05).

Analysis of both irradiated and non-irradiated patients revealed that local and regional recurrence was determined independently by pathologic T (pT) stage, tumour localization, radiation status and pN stages (p < 0.05). The distant metastasis rate significantly depended on N stage and tumour localization (p < 0.05) and the rate of formation of multiple primary tumours was significantly affected by the patient's age and radiation status (p < 0.05).

In conclusion irradiation of laryngeal cancer patients independently increases the risk of local and regional recurrence, and also increases the risk of multiple primary tumours while not significantly influencing the risk of distant metastasis. The risk of distant metastasis is affected by determinants of advanced lesions and tumour localization.

Our aim was to ascertain the current practice of adjuvant therapy for tonsillectomy and to determine whether it is evidence based. Anonymized postal questionnaires were sent to all UK otolaryngology consultants registered with the specialty association, and a literature search was performed using relevant search terms in all possible combinations. Among the responders there was little enthusiasm for routine intra-operative local anaesthesia, post-operative topical benzydamine hydrochloride (Difflam) spray or post-operative antibiotics. This is consistent with the lack of robust evidence to support any of these practices. Paracetamol (acetaminophen) is prescribed by almost 90 per cent for post-operative analgesia, and the current literature supports its efficacy and safety. Further, most practitioners combine paracetamol with opioids and/or non-steroidal anti-inflammatory drugs (NSAIDs). Evidence to support the additional use of these agents is, however, non-existent or limited. Some aspects of tonsillectomy care are uniform and evidence based. Others are heterogeneous and suffer from lack of adequate data in the literature.

Endoscopic sinus surgery procedure using CO2 laser and/or microresector for paediatric and adult chronic sinusitis with antrochoanal polyp (ACP), with long-term follow-up, was examined. Twelve children and 13 adults underwent the surgical procedure.

The following two techniques were used to remove the antral portion of an ACP with a 70°endoscope:

(1) CO2 laser – The base of the ACP was vaporized and removed via an enlarged natural ostium with a pipe-guide handpiece with a deflective tip.

(2) Microresector – The ACP was resected via an enlarged natural ostium and/or nasoantral window opened under the inferior turbinate with the curved and straight blade of a microresector.

In the endoscopic follow up for 10 to 57 months, no patient who underwent the primary surgery required reoperation for ACP recurrence. One out of the seven patients who underwent secondary surgery required a revised operation with microresector and CO2 laser.

Ankylosing spondylitis (AS) is a chronic inflammatory disease. The aim of this investigation was to study the relationship between AS and hearing loss. This study compared 28 patients with AS with 23 age-matched controls. All subjects underwent ENT examination, audiological and acoustic immittance measurements, and auditory brainstem response (ABR) tests. Sensorineural hearing loss was found in 28.6 per cent of the AS patients and in 4.35 per cent of the control group. For hearing levels at 250–500 Hz and 4000–8000 Hz, there was a statistically significant difference between the two groups. Acoustic reflex was not obtained in both ears of four patients and the left ear of one patient. There was a correlation between increase of tympanic volume and limitation in neck movement, between extension of 1–3 interpeak latency and limitation in the neck movement. In conclusion, AS affects the inner ear more than the middle ear.

This study assessed the effect on the upper airway during sleep nasendoscopy of mimicking the action of a mandibular advancement splint. Twenty-seven subjects with a diagnosis of sleep-disordered breathing were referred for mandibular advancement splint therapy following sleep nasendoscopy. Sleep nasendoscopy was repeated for all subjects with, and without, the appliance in situ. Follow-up sleep studies with a mandibular advancement splint in situ were undertaken for 19 individuals with significant obstructive sleep apnoea.

With the mandibular advancement splint, subjective snoring levels and airway patency improved as predicted in all but one individual. Residual palatal flutter was predicted for five subjects and occurred in eight individuals. Follow-up sleep studies showed highly statistically significant reductions in median apnoea-hypopnoea index (from 28.1 to 6.1, p < 0.001).

Mimicking the action of a mandibular advancement splint during sleep nasendoscopy helps considerably in the patient selection process for this form of treatment.

Most of the previous treatment methods for auricular haematoma are inconvenient for both patients and doctors because they are time-consuming and complex and must be performed under sterile conditions. The purpose of this study was to evaluate the effectiveness of a simple compressive method using a dental (silicone) impression material and comparing it with other methods for treatment of auricular haematomas. The authors aspirated a haematoma and then placed a mixed base and catalyst of silicone putty material on the anterior and posterior surfaces of the auricle in the shape of an inverted U for seven days.

From the 24 cases managed with this method, 23 cases (95.8 per cent) were successfully healed. Eight patients were treated with a collodion-cotton wool cast and 16 of 19 patients were successfully treated with dental cotton-wool rolls. The average number of those visiting the hospital was 2.7 for the collodion-cotton wool cast, 6.9 for the dental cotton-wool roll, and 3.1 for dental silicone. The mean treatment durations were 8.1 days for the collodion-cotton wool cast, 13.8 days for the dental cotton-wool roll, and 8.6 days for dental silicone. The authors believe that this compressive method using dental silicone material is simple and appropriate for the treatment of auricular haematoma.

Introduction: The relative incidence of paediatric Bell’s palsy is two to four times less than the condition in adults. The number encountered in our otolaryngology department falls short of the above prediction. This could either reflect the general practitioners' (GPs) patterns of referral or a lower incidence in our locality.

Methods: Postal questionnaires were sent to our local GPs to determine their referral practice when managing children presenting with acute facial paralysis.

Results: Of 233 questionnaires, 172 (74 per cent) were returned and analysed. Fifty-four per cent of GPs referred their patients to the local paediatric services, 22 per cent to an otolaryngologist, and the remaining 24 per cent of GPs were confident in diagnosing and managing Bell's palsy in children themselves.

Discussion and Conclusion: Of the GPs surveyed 78 per cent did not refer children presenting with acute facial paralysis to an otolaryngologist. We suggest minimum investigations for acute facial paralysis in children before diagnosing Bell's palsy and stipulate otolaryngology referral for all.

Background: Idiopathic sudden sensorineural hearing loss (ISSHL) and tinnitus are common. Hyperbaric oxygen therapy (HBOT) may improve hearing loss and/or reduce the intensity of tinnitus.

Methods: We performed a systematic search of the literature for randomized controlled trials, and made pooled analyses of pre-determined clinical outcomes where possible.

Results: Six trials contributed to this review (304 subjects). Pooled analysis suggested a significantly increased chance of a 25 per cent improvement in hearing threshold on pure tone average with HBOT (relative risk (RR) 1.39, 95 per cent confidence interval (CI) 1.05–1.84, p = 0.02; number-needed-to-treat 5, 95 per cent CI 3–20), but not a 50 per cent increase (RR 1.53, 95 per cent CI 0.85–2.78, p = 0.16). The significance of any improvement in tinnitus following HBOT could not be assessed due to poor reporting.

Conclusions: HBOT improved hearing, but the clinical significance of the level of improvement is not clear. Routine application of HBOT to patients with ISSHL is not justified by this review. More research is needed.

Objective: The course and the long-term outcome of ’refractory’ secretory otitis media (SOM), defined as continuous SOM for more than 6 years, were studied in 52 young patients. They had during childhood been treated for bilateral SOM on average for 12 years (range 6 to 26 years). The mean interval between resolution of SOM and examination was 7 years.

Methods: At follow up the patients’ medical records were scrutinized with regards to transmyringeal ventilation tubes, adenoidectomy, sequelae and complications, and a questionnaire was filled in to document other diseases.

Results: The onset of SOM showed two peaks, one at the age of one year and one at the age of 3.5 years. Patients whose onset of SOM was related to an episode of acute otitis media (AOM) were younger at SOM onset than those who had no such relation. Otorrhoea and AOM episodes were more frequent during the SOM periods, with blocked or expelled tubes, than during periods with patent tubes. Cholesteatoma were seen in 3 per cent and perforations in 5 per cent of patients.

Conclusions: Extremely long-standing SOM does not necessarily result in myringeal perforation or cholesteatoma to a greater extent than that seen in patients with shorter durations of SOM. However, at follow up one-third of the patients reported hearing impairment and a majority felt discomfort when flying or diving.

This study determined the prevalence of migraine and allergy in patients with Ménière’s disease (MD) compared with age- and sex-matched controls. We tested the hypothesis that if migraine and MD is linked by allergy, then allergy should be more prevalent in patients with MD and migraine compared with MD patients without migraine.

A web-based questionnaire was used to recruit patients with MD (n = 108) while the control group consisted of patients attending the ENT clinic for other problems (n = 100).

The prevalence of migraine and allergy was significantly higher in patients with MD compared with age- and sex-matched controls (p ≥ 0.005). In addition, the prevalence of allergy was significantly higher in patients who had both MD and migraine (30/42) than MD alone (26/66,p = 0.002). However, there was no link with any specific allergy types.

This study suggests that migraine and MD may be linked by an immunological determinant.

The aim of this study was to compare the effectiveness of technetium-99m methoxyisobutylisonitrile (99mTc-MIBI) single-photon emission computed tomography (SPECT) and computed tomography (CT) in evaluating cervical lymph node metastasis of head and neck cancer. Histopathologic results of 166 cervical lymph node levels in 31 neck-dissected patients were compared with pre-operative CT and 99mTc-MIBI SPECT findings about cervical lymph node metastasis, retrospectively. Sensitivity, specificity and predictability of CT and 99mTc-MIBI SPECT were 68.2, 93.1 and 89.8 per cent and 59.1, 87.5 and 83.7 per cent, respectively. When analysing CT and99mTc-MIBI SPECT together, sensitivity and specificity were 86.4 and 99.3 per cent, respectively. The combined use of 99mTc-MIBI SPECT and CT could increase the accuracy of cervical lymph node metastases detection, compared with separate use of either 99mTc-MIBI SPECT or CT.

’Action on ENT’ has recently published advice as to the minimum requirements for equipment required to provide a safe and suitable out-of-hours service in ENT.

Our objectives were to determine the availability of a dedicated ENT treatment room for seeing patients out of hours, appropriately maintained specialized ENT equipment and availability of appropriate assistance. In addition, the mechanism for disinfection of nasoendoscopes out of hours was determined.

Telephone questionnaires of 106 ENT units in England, which provide an out-of-hours ENT service, were taken. At each unit the standard questionnaire was answered by the first on-call ENT doctor.

One hundred and one units (95 per cent) had access to a dedicated treatment room out of hours. The number of units with a microscope was 91 (86 per cent), headlight/lamp and mirror was 105 (99 percent), flexible nasoendoscope was 86 (81 per cent) and cautery (electrical or chemical) was 105 (99 per cent). Seventy-nine units (75 per cent) found that their treatment rooms were adequately stocked, and 62 units (58 per cent) had assistance available when needed. Twenty-four units (23 percent) sterilized their scopes adequately, 22 units (21 per cent) used endosheaths, 26 units (24 per cent) used a variety of inadequate cleaning methods, and 34 respondents (32 per cent) were unsure how their scopes were cleaned.

This survey has shown that not all ENT units have appropriately equipped out-of-hours facilities. There is a need for nationally agreed guidelines stating the minimum equipment and assistance required to provide a safe, adequate and suitable out-of-hours service. National guidelines on out-of-hours disinfection of flexible nasoendoscopes are also required.

Otic barotrauma occuring during air travel involves traumatic inflammation of the middle ear, caused by a pressure difference between the air in the middle ear and the external atmosphere, developing after ascent or more usually descent. The pressure difference occurs because of failure of the eustachian tube to equilibrate middle ear and atmospheric pressures. It is a common problem, presenting with ear fullness, otalgia and deafness. Severe cases may result in tympanic membrane perforation and even round window membrane rupture. Of three randomized controlled trials, one showed that oral pseudoephedrine decongestants reduced otalgia inadults with recurrent ear pain during air travel, whilst another found that oral pseudoephedrine did not decrease in-flight ear pain in children. The third trial showed that oxymetazoline decongestant nasal spray, taken 30 minutes before descent, did not produce a statistically significant reduction in symptoms of barotrauma in adults with recurrent ear pain during air travel. We review the causes, prevention and treatment of this condition.

Objective: To describe endoscopic management of frontal sinus cerebrospinal fluid (CSF) leaks.

Study design: Retrospective.

Methods: We reviewed all frontal sinus CSF leaks treated using an endoscopic approach at ourinstitutions from 1998 to 2003. CSF leaks originated immediately adjacent to or within the frontal recess or frontal sinus proper for inclusion in the study. Data collected included demographics, presenting signs and symptoms, site and size of skull-base defect, surgical approach, repair technique, and clinical follow up.

Results: Seven frontal sinus CSF leaks in six patients were repaired endoscopically. Average age of presentation was 45 years (range 25–65 years). Aetiology was idiopathic (three), congenital (one), accidental trauma (one), and surgical trauma (two). All patients presented with CSF rhinorrhea; two patients presented with meningitis. Four defects originated in the frontal recess, while two others involved the posterior table and frontal sinus outflow tract. Four patients had associated encephaloceles. We performed endoscopic repair in all six patients withone patient requiring an adjuvant osteoplastic flap without obliteration. All repairs were successful at the first attempt with a mean follow up of 13 months. All frontal sinuses remained patent on both post-operative endoscopic and radiographic exam.

Conclusions: Endoscopic repair of frontal sinus CSF leaks and encephaloceles can be an effective method if meticulous attention is directed toward preservation of the frontal sinus outflow tract, thus avoiding an osteoplastic flap and obliteration. The major limiting factor for an endoscopic approach is extreme extension superiorly or laterally within the posterior table beyond the reach of current instrumentation.