The authors describe a novel use of a de-epithelialized deltopectoral flap for the closure of tracheo-oesophageal fistulae, which have been resistant to other methods of closure.

Deep neck abscesses (DNAs) continue to be commonly encountered in developing countries like India. This study was conducted to determine the changing trends within our population with respect to presentation, aetiology, location and microbiology of DNAs. Fifty-four patients with DNAs who were managed at the Department of ORL and H&N Surgery in our hospital between May 2002 and December 2002 formed the basis of the study. We observed that the high incidence of DNAs could be attributed to lack of awareness, illiteracy and poverty among patients, along with the poor primary health infrastructure. We also recommend early surgical intervention in these cases to decrease the prevalence of complications.

Jejunal free-flap reconstruction is a well recognized, reliable technique commonly used for reconstruction of the upper aero-digestive tract following surgery for malignancy, and radiotherapy is commonly used as an adjuvant treatment in such cases. Unfortunately, post-irradiation sarcomas are a well recognized complication of radiotherapy and generally have a poor prognosis. We report what we believe to be the first case of radiation-induced sarcoma in a free-flap jejunal graft and discuss the information that should be given to patients undergoing radiotherapy to head and neck tumours.

Since the first reliable mediastinal tracheostomy described by Grillo et al. in 1966, many new techniques have been described in order to reduce the number of complications. We here report the case of a 55-year-old man who was referred for surgery with post-radiochemotherapy recurrence of a double neoplasm of the pharyngolarynx extending to the proximal trachea and the medial part of the oesophagus. Through a median sternotomy, a pharyngolaryngoesophagectomy was performed with an extended tracheal resection. The reconstruction of the upper digestive tract was performed with a gastric pull-up. The mediastinal tracheostomy was performed with a pectoralis major muscular flap through a right unilateral resection of the manubrium, the right clavicular head and the right first and second costal cartilages. Historically, the mediastinal tracheostomy was performed through a large bilateral resection of the anterior chest wall, in order to prevent the tension on the tracheocutaneous sutures. Nowadays, with the possibility of various pedicled flaps, bilateral resection no longer seems to be necessary. This unilateral resection leads to a reduction in post-operative sequelae.

The pectoralis major myocutaneous (PMMC) flap is commonly used for head and neck reconstruction especially in impoverished nations. PMMC is a sturdy pedicled flap with relatively fewer complications, the learning curve is short and no specialized training in microvascular surgery is needed in order to use this flap. In a defect that requires a large skin and mucosal lining the authors routinely use either a bi-paddle PMMC or a combination of PMMC (for the mucosal lining) and a delto-pectoral flap (for the skin defect). It is indisputable that free tissue transfer is a better way of reconstruction for the majority of most such defects. Unfortunately, not all patients can be offered this form of reconstruction due to the cost, time, expertise and infrastructural constraints in high volume centres such as ours. Bi-paddling of PMMC is hazardous in obese males and most female patients. In such patients the skin defect is reconstructed usually by the delto-pectoral (DP) flap but this, for obvious reasons, is less welcomed by the patients. The authors suggest a technique wherein mucosal lining is created by the myofascial lining (inner surface) of the flap and the skin defect is reconstructed by the skin paddle of the single paddle PMMC. It should be considered wherever a DP flap is unacceptable, or bi-paddling or free tissue transfer is not possible.

Mass lesions of the head and neck in infants and children can be either developmental, inflammatory or neoplastic. Lymphomas (Hodgkin’s or Non-Hodgkin’s) commonly present as neck lumps in children. Although malignancy is not the commonest aetiology of paediatric cervical lumps, a high index of suspicion is critical to facilitate early diagnosis and treatment of cervical lesions. We present the case of a 15-year-old boy who presented with a solitary midline cervical lesion, which simulated a thyroglossal cyst on clinical examination. However, histopathological examination revealed it to be a Hodgkin’s lymphoma. Related literature is also reviewed.

Brown-Vialetto-Van Laere syndrome, or pontobulbar palsy with deafness, is a rare disorder characterized by bilateral sensorineural deafness and a variety of cranial nerve disorders usually involving the motor components of the lower cranial nerves. Less commonly, spinal motor nerves and upper motor neurons are involved. Familial and sporadic cases have been reported. Based on evidences, this syndrome has been related to autosomal recessive, autosomal dominant and X-linked inheritance. Autoimmune origin has been considered as well.

In this paper, we report the case of a 38-year-old female patient who primarily presented with bilateral sensorineural hearing loss and then progressively developed Xth and VIIth cranial nerve paralysis. Brown-Vialetto-Van Laere syndrome was diagnosed with this symptom complex of sensorineural hearing loss and pontobulbar palsy.

Objective: Although fibre-optic bronchoscopic intubation is well recognized as the most valuable adjunct for elective management of the difficult airway its precise role in oncological head and neck emergencies has not been evaluated. The objective of this study was to evaluate the role of fibre-optic intubation in such emergencies.

Methods: This was a consecutive case series study by a single surgeon (the otolaryngologist) and anaesthetist team, taking place in a regional tertiary-referral head and neck surgical oncology centre. A series of 17 consecutive oncological head and neck emergency patients underwent fibre-optic intubation with a Portex endotracheal tube of inner diameter ≥7 mm, with the aid of a 6-mm (EB-1830T2) Pentax fibre-optic video bronchoscope. The study assessed occurrence of: avoidance of tracheostomy in bleeding emergencies; a well placed, uncomplicated tracheostomy in airway obstruction; and successful intubation.

Results: Two cases were decannulated completely. All cases were successfully intubated and a tracheostomy was avoided in all cases in which emergency intubation was required and the patient was bleeding. We conclude that fibre-optic bronchoscopic intubation is a viable option in head and neck oncological emergencies due to upper airway obstruction and tumour bleeding. Clinical and endoscopic judgement and operator experience are the key factors determining success.

The purpose of this study was to dissect various animal larynges in support of a proposal for a laryngeal dissection laboratory. It was found that although the bovine larynx is larger than the human larynx, the anatomy is similar. Thirty-three bovine larynges were dissected by the author in various simulated phonosurgical and partial laryngectomy procedures. Following each procedure, the specimen was photographed for teaching purposes. The author concludes that dissecting bovine larynges offers a valuable aid to training in the field of laryngeal surgery. It is intended to apply these dissections in the form of a departmental surgical workshop.

Foley’s catheter is used for post-nasal packing in severe epistaxis. Various methods have been described for securing the catheter in position, all of which can be associated with patient discomfort, risk of alar necrosis or unsightliness. We describe a new method to secure the Foley’s catheter without these problems. The ribbon gauze used for anterior nasal packing is tied over the catheter in multiple knots to secure it in place. This has been successfully tried on over 50 patients.

The Norfolk and Norwich retractor is a vital tool in head and neck surgery. It is of great aid in training junior surgeons and has become an integral part of the standard neck dissection instrument set in our unit. This retractor enables good exposure of the carotid sheath, its atraumatic blunt tip retracting the carotid sheath without damage. It makes a single skin incision for neck exposure possible, rather than a Y, T or wine glass incision, avoiding a three-point junction, especially in the post-irradiated neck. In thyroid surgery it reduces the need for manual retraction thereby relieving the assistant surgeon and enhancing the quality of the learning experience.

Visual reinforcement audiometry (VRA) is an important behavioural test of hearing in young children. The use of insert earphones during VRA provides a reliable method of obtaining ear- and frequency-specific data. Two testers are usually required for this procedure. The first tester operates the audiometer and other controls while the second tester distracts the child with various toys. The paper describes a technique of providing a visual cue to the second tester when a sound stimulus is introduced through the insert earphones.

Background: Apert syndrome is one of the craniosynostosis syndromes, with abirth prevalence estimated to be between 9.9 and 15.5/million, and accounts for 4.5 per cent ofcraniosynostoses. Although conductive hearing loss is common in Apert syndrome there are contradicting reports regarding the cause of this hearing loss. There is also no detailed informationavailable on the management of hearing loss in Apert syndrome.

Materials and methods: A retrospective analysis of case notes of Apert syndrome patients seen between 1970 and 2003 at Great Ormond Street Children’s Hospital, London, was undertaken.

Results: Seventy case notes were obtained. The incidence of congenital hearing impairment was between 3 and 6 per cent. Almost all patients had otitis media with effusion (glue ear), which tended to persist into adult life. More than 56 per cent of cases developed permanent conductive hearing loss by 10–20 years. Repeated grommet insertion was common; even though 35 per cent had trouble with ear discharge and persistent conductive hearing loss. Statistically, grommets made no difference to the risk of developing permanent hearing loss.

Conclusion:This study, of the largest number of Apert syndrome cases assembled to date, showed that early optimization of hearing with possible hearing aids needs to be considered. Repeated grommet insertion does not help in optimizing hearing, especially if ear discharge complicates the picture.

Epistaxsis and crustation are common problems associated with long-term use of oxygen through nasal prongs in patients suffering from chronic obstructive pulmonary disease. The nasal prong can cause direct trauma to the septal mucosa. We describe a simple solution to this problem with use of the disposable ear tip used in tympanometry

Herpes simplex virus (HSV) encephalitis is a life-threatening consequence of HSV infection of the central nervous system. Although HSV encephalitis is rare, mortality rates reach 70 per cent in the absence of therapy and only a minority of individuals return to normal function. Antiviral therapy is most effective when started early, necessitating prompt diagnosis.

A case of atypical HSV encephalitis is reported. The appearance of a strong headache followed by impairment of consciousness and hypertone of arms and legs complicated the post-operative course in a 33-year-old patient who underwent surgical removal of an acoustic neuroma. Several brain magnetic resonance imaging (MRI) and computed tomography scans performed in the first week after onset of symptoms of infection did not establish a proper diagnosis. Diffusion-weighted MRI detected brain abnormalities on the fourth day after onset of symptoms, and polymerase chain reaction identification of HSV 1 DNA confirmed the diagnosis. A positive prognosis was achieved due to the decision to start specific, high-dose antiviral therapy based on clinical suspicion, before a firm diagnosis was established.

We present the unusual case of a 54-year-old diabetic man with chronic suppurative otitis media, presenting with cervical osteomyelitis and retropharyngeal abscess. This was treated with decompression, debridement and fusion from C2 to C4 with external halo-frame stabilization. Pseudomonas aeruginosa was cultured from the ear and the osteomyelitis specimen. Exploration of the left ear showed evidence of mucosal disease, with granulations in the middle ear and oedematous mucosa in the mastoid antrum, but no evidence of dural-plate dehiscence. Haematogenous spread probably led to cervical osteomyelitis and retropharyngeal abscess formation. Cervical osteomyelitis may develop as a rare complication and present as a cause of severe neck pain in patients with otitis media.

Venous thromboembolic disease has an estimated annual incidence of one in 1000 people. However, thrombosis of the superior mediastinum and neck veins is less frequent and it is usually due to direct trauma to the neck by intravenous catheters, drug abusers or neck dissection surgery. Local or distant malignancy (Trousseau’s syndrome) is also an important cause.

Thrombosis of the superior mediastinal and internal jugular veins is rarely a cause of primary referral to the otolaryngologist. On these rare occasions, it can present as a painful neck mass, but may also present with stridor, dysphonia or dysphagia. The four patients presented here illustrate different ways of presentation. Different imaging techniques such as ultrasound, computed tomography (CT) scan, magnetic resonance imaging (MRI) and venogram, will produce a diagnosis of thrombosis, occasionally with a mass, but only a biopsy will confirm or rule-out malignancy.

Spontaneous thrombophlebitis can be the first manifestation of an occult neoplasm and any investigation into venous thrombosis must include a thorough general examination and follow up.

Adult rhabdomyosarcomas in the head and neck are extremely rare and carry a poor prognosis. They should be considered as a distinct clinical entity. The authors report a case of embryonal rhabdomyosarcoma in an adult nasopharynx treated with a combined modality treatment of chemotherapy and radiotherapy as per the European International Society of Paediatric Oncology (SIOP) MMT 89 study, group D. The patient responded to treatment and 10 years later, he is still alive with no signs of metastatic disease.

We present a patient with an inflammatory pseudotumour of the neck with multifocal sites in the head and chest responding to steroids. A review of the literature revealed that this is the first case of a pseudotumour with multiple sites in the head and neck as revealed by 2-[18]fluorodeoxyglucose(FDG) PET scan imaging.