Evidence from the literature shows that clinicians’ knowledge of rules and legislation surrounding driving can often be poor. A closed-loop audit was conducted to gauge the level of driving advice given to patients with dizziness.

The clinical notes of 100 patients referred to the vertigo clinic at a tertiary referral centre were retrospectively searched for evidence of driving advice. Education sessions were undertaken and a patient information leaflet was developed before a second cycle of the audit.

The proportion of patients having documented evidence of receiving driving advice increased from 6.3 per cent to 10.4 per cent. It is therefore clear that, despite this improvement, a significant proportion of patients’ notes did not contain documentation about driving. This is likely because of many reasons, including individual interpretation by clinicians. This paper provides a reminder of the rules, and discusses their interpretation and implementation in an increasingly medicolegal environment.

To evaluate the healing and hearing outcomes related to the everted or inverted edge area on slap- and fist-induced large tympanic membrane perforations.

A total of 120 patients with slap- or fist-induced tympanic membrane perforations, with inverted or everted edges, affecting 50–75 per cent of the entire tympanic membrane, were randomly divided into 2 groups: an edge approximation group and a spontaneous healing group. The edge approximation group was divided into subgroups A and B based on the reversed edge area (reversed edge was more or less than 50 per cent of the total perforation, respectively). Healing outcomes and hearing improvements at six months were compared.

The data of 118 patients were analysed. The closure rate of perforations in subgroup A, subgroup B, and the spontaneous healing group was 90.9 per cent, 92.1 per cent and 84.5 per cent, respectively; the difference between the three groups was not significant (p = 0.393).

The area of reversed edges for slap- or fist-induced tympanic membrane perforations did not seem to affect healing and hearing outcomes, regardless of edge approximation and everted or inverted edges.

This study gives details of a rare case of petrous apicitis that presented as Gradenigo's syndrome and was managed surgically.

This study presents a case report and review of the literature.

A four-year-old female was admitted for failure to thrive following recent sinusitis. Physical examination was positive for right sided facial pain, photophobia and right abducens nerve palsy. Subsequent magnetic resonance imaging revealed a 1.3 × 1.7 × 1.4 cm abscess encompassing the right Meckel's cave. A computed tomography scan showed petrous apicitis and otomastoiditis, confirming Gradenigo's syndrome. The patient was taken to the operating theatre for right intact canal wall mastoidectomy with myringotomy and tube placement. She was discharged on six weeks of ceftriaxone administered by a peripherally inserted central catheter line. At a two-week post-operative visit, she showed notable improvement in neuropathic symptoms.

This study presents a rare case of petrous apicitis managed surgically without the need for a craniotomy or transcochlear procedure.

Radiotherapy is an option to treat high-grade laryngeal dysplasia. This study aimed to evaluate the use of intensity-modulated radiotherapy, 55 Gy in 20 daily fractions, in treating this disease.

Acute toxicity was evaluated in all 14 patients treated. In 10 patients, functional voice outcome was measured using the Voice Handicap Index, and the Grade, Roughness, Breath, Asthenia, Strain (‘GRBAS’) scale. These measurements were performed pre-treatment and three months after intensity-modulated radiotherapy.

All but one patient managed to complete radiotherapy. Acute toxicity was significant (one patient developed grade 4 and three patients developed grade 3 dysphagia). Four patients required hospital admission. In 9 out of 10 patients, radiotherapy improved voice quality.

This radiotherapy regimen using intensity-modulated radiotherapy for laryngeal dysplasia is feasible and provided excellent functional outcome, but acute toxicity was significant. Dose de-escalation can be considered in the framework of clinical trials.

Silver nitrate cautery and bipolar electrocautery are commonly used in the treatment of epistaxis. Currently, there are no recommendations on optimum contact times or power for nasal cautery. ENT consultant practice in the UK has not previously been evaluated.

This study examined the burn depth associated with silver nitrate (75 per cent concentration) cautery and bipolar electrocautery on porcine septum samples, using varying contact times and power. ENT consultants completed a survey evaluating their practice.

ENT consultant practice of nasal cautery was shown to vary widely. Silver nitrate cautery with a contact time of less than 30 seconds does not cause a full thickness burn. The findings lend some support to bilateral cauterisation with silver nitrate. Bipolar electrocautery should be set at lower than 10 W and with a contact time of less than 4 seconds to reduce the risk of complications associated with a full thickness burn.

Little is known about what shapes the choice of employment location in a competitive surgical specialty like otolaryngology – head and neck surgery. This study aimed to identify factors important in determining practice location among Canadian otolaryngologists

An online survey was distributed nationally to active members of the Canadian Society of Otolaryngology – Head and Neck Surgery. The survey collected data on general demographics, current practice description, training location, factors deemed important in practice location decisions, and job satisfaction.

A total of 122 survey responses were collected, with a similar proportion of participants in academic versus community practice. The majority of respondents (73 per cent) practised in the same province as their residency training. Participants identified job vacancy, colleague interaction, spouse opinion and hospital services as important in the decision of practice location.

Key determinants of practice location among Canadian otolaryngologists include job vacancies, spouse opinion, and colleague interactions. Overall, Canadian otolaryngologists report high satisfaction with current employment.

Autoinflation devices are commonly used for otitis media with effusion and Eustachian tube dysfunction. Generally, these are very safe devices, with few or no complications.

This paper presents a case study of pneumocephalus and orbital emphysema, associated with the use of an autoinflation device, in a 73-year-old woman with Eustachian tube dysfunction and otitis media with effusion, and a history of extensive endoscopic sinus surgery 13 years previously.

A literature review showed autoinflation-related pneumocephalus in patients with skull base defects relating to cranial surgery or tumours; however, this has not been described previously with the Otovent system or its use in relation to functional endoscopic sinus surgery. Given the theoretical risk of undetected bony abnormalities in post-operative functional endoscopic sinus surgery patients, it is suggested that autoinflation devices are used cautiously in patients with a history of sinus surgery.

The transmastoid pre-sigmoid approach is always the preferred choice for implantation of the Bonebridge active bone conduction system in patients with a normal anatomy. When an anatomical variant exists or a previous surgery has been performed, a retrosigmoid approach or middle fossa approach can be performed.

The preferred surgical technique for a middle fossa approach is described. A 14 mm drill head (Neuro Drill) was used to create the bed at the squamous portion of the temporal bone. Surgical time and complication rate were analysed.

The surgical time was shorter than 30 minutes in all cases, and only 14 seconds were needed to create a 14 mm bone bed. No complications were observed during the follow-up period (6–45 months).

Use of the Neuro Drill for the middle fossa approach is an easy technique. It significantly decreases the surgical time, without increasing the complication rate.

Disorders of voice can limit an individual's participation and impair social interaction, thus affecting overall quality of life. Perceptual and objective evaluations can provide the clinician with detailed information regarding voice disorders.

This study comprised 40 subjects aged 34–46 years, 20 of whom (10 male, 10 female) had unilateral vocal fold palsy. Data were obtained for all participants from: the Voice Handicap Index, the grade, roughness, breathiness, asthenia and strain (‘GRBAS’) scale, acoustic voice analysis, electroglottography, and voice range profiles.

The voice evaluations revealed statistically significant (p < 0.05) differences between the controls and study group, both in males and females, pre- and post-therapy.

Despite the normalisation of vocal parameters, acoustic, perceptual and self-rated assessments revealed statistically significant differences after therapy. Hence, acoustic measures, namely electroglottographic perturbation, and voice frequency and intensity range, are recommended prior to termination of therapy.

In November 2017, a working feasibility analysis commenced of a local anaesthetic endonasal procedures out-patient clinic service at Freeman Hospital, Newcastle upon Tyne. Fundamental to introducing an innovative ambulatory out-patient practice is the development of a novel local safety standard for invasive procedures to support this service.

This paper presents the new safety standard developed for this purpose and implemented in our institution.

Increasingly, there is a shift toward ambulatory services, directed by patient choice, technological advances and the opportunity for cost savings. It is hoped that this local safety standard for invasive procedures will provide a useful template for those considering implementing ambulatory endonasal services, or other novel procedures, within the specialty of ENT.

Tracheocutaneous fistula represents one of the most troublesome complications of prolonged tracheostomy. Simple closure of a fistula can be ineffective, particularly in the context of prior surgery and adjuvant radiation. As such, modes of repair have expanded to include locoregional flaps and even free tissue transfers.

This paper describes a case of persistent tracheocutaneous fistula in an irradiated patient who had undergone previous unsuccessful attempts at repair.

The use of regional fasciocutaneous supraclavicular flap with prefabricated conchal bowl cartilage resulted in successful closure of the tracheocutaneous fistula.

This represents a novel technique for closure of such fistulas in patients for whom previous attempts have failed. This mode of repair should be added to the surgeon's repertoire of reparative techniques.

Obstructive sleep apnoea occurs consequent to partial or complete upper airway obstruction, caused mostly by the collapse of upper airway musculature. Drug-induced sleep endoscopy represents the ‘gold standard’ in identifying the obstruction site, from the palatal level to laryngeal entry. Breathing impairment in sleep caused by the collapse of cervical trachea after previous tracheostomy has not yet been described in the literature.

This report presents two patients with severe obstructive sleep apnoea, in whom pre-operative drug-induced sleep endoscopy revealed upper airway and cervical trachea collapse at the level of previous tracheostomy.

The female patient was successfully treated with resection of hypertrophic tissue of the tongue base via lateral pharyngectomy, and resection of the collapsed segment of the trachea with primary reconstruction of the trachea by end-to-end anastomosis. The male patient was recommended continuous positive airway pressure therapy because of serious co-morbidities and high operative risk.

Drug-induced sleep endoscopy should always be used for visualisation of anatomical structures below the vocal folds in patients with a history of cervical trachea surgery. These two cases demonstrate the importance of drug-induced sleep endoscopy in planning conservative and surgical treatments, contributing significantly to operative success.

All patients undergoing tympanomastoid surgery should be assessed post-operatively for a ‘dead ear’; however, tuning forks are frequently inaccessible.

To demonstrate that smartphone-based vibration applications provide equivalent accuracy to tuning forks when performing Weber's test.

Data were collected on lay participants with no underlying hearing loss. Earplugs were used to simulate conductive hearing loss. Both the right and left ears were tested with the iBrateMe vibration application on an iPhone and using a 512 Hz tuning fork.

Occluding the left ear, the tuning fork lateralised to the left in 18 out of 20 cases. In 20 out of 20 cases, sound lateralised to the left with the iPhone (chi-square test, p = 0.147). Occluding the right ear, the tuning fork lateralised to the right in 19 out of 20 cases. In 19 out of 20 cases, sound lateralised to the right with the iPhone (chi-square test, p > 0.999).

Smartphone-based vibration applications represent a viable, more accessible alternative to tuning forks when assessing for conductive hearing loss. They can therefore be utilised on the ward round, in patients following tympanomastoid surgery, for example.

This study investigated the position of adduction thread attachment, pulling direction and fixation position in revision arytenoid adduction surgery performed in two patients with left vocal fold palsy in whom satisfactory speech improvement had not been obtained by arytenoid adduction and type 1 thyroplasty.

Revision arytenoid adduction surgery was performed with the vocal fold in the midline position in both cases. A type 1 thyroplasty procedure was subsequently added in one case because of worsened quality of speech following arytenoid adduction.

Although the arytenoid adduction procedure is conceptually well established, there is still room for debate concerning the actual surgical procedures used. The technique described in this report is effective, suggesting that it is worthy of recognition as an index procedure.

Parapharyngeal abscess and mediastinitis are rare but very severe post-operative complications following an elective tonsillectomy. Parapharyngeal abscess as a complication to tonsilectomy is very seldom described in the literature and no cases in the paediatric population have been described.

This paper presents, to our knowledge, the first case of life-threatening parapharyngeal abscess and mediastinitis following elective adenotonsillectomy in an otherwise healthy, fully vaccinated 10-year-old girl.

Diagnosing parapharyngeal abscess and mediastinitis can be challenging, but should be suspected and ruled out in cases of post-operative odynophagia, fever, and/or neck swelling and thoracic pain. Diagnosis is made based on magnetic resonance imaging and computed tomography findings. Prompt broad-spectrum intravenous antibiotic treatment and surgical drainage should be initiated. Other severe complications such as meningitis should also be considered.

Surgical techniques for resistant chronic rhinitis (rhinorrhoea) vary, ranging from vidian neurectomy to post-nasal neurectomy. The techniques vary mainly on the basis of instrumentation, and the avoidance of post-operative epistaxis, transient hypoesthesia of the soft palate and dryness of the eye. Endoscopic visualisation, and cauterisation or resection of posterior nasal nerve branches, can prevent such complications.

The technique and surgical steps of endoscopic posterior nasal neurectomy are presented.

The critical steps include: bilateral sphenopalatine nerve blocks, transnasally or transorally via the greater palatine foramen; vertical incisions made behind the posterior fontanelle; and elevation of the mucoperiosteal flap. The sphenopalatine foramen and artery is identified. The posterior nasal nerve is located 4–5 mm inferior to the sphenopalatine artery, and is resected or cauterised. The flaps are repositioned back into place. No post-operative nasal packing is required. The same procedure is performed on the opposite side for effective results.

This technique provides consistent, robust results, with long-term relief of allergic and vasomotor rhinitis related nasal symptoms, without risk of complication.

To discuss the reasons for misdiagnosis of supernumerary nasal teeth.

Clinical data of four supernumerary nasal tooth patients were analysed retrospectively at visits to our otolaryngology department between 2005 and 2018.

All four patients were male and had a supernumerary nasal tooth in the right nasal cavity. Three of the four patients had previously been misdiagnosed. All the supernumerary nasal teeth were surrounded by granulation tissue or hypertrophic nasal mucosa, and were subsequently confirmed by computed tomography and endoscopy. The granulation tissue or hypertrophic nasal mucosa was removed using microwave ablation, and the supernumerary nasal teeth successfully removed by endoscopy.

Supernumerary nasal teeth are rare, and are usually misdiagnosed because such teeth are surrounded by hypertrophic nasal mucosa or granulation tissue. They can be confirmed by computed tomography and endoscopy.

Cutaneous squamous cell carcinoma is usually associated with long-term ultraviolet light exposure. Human papillomavirus 16 is a high-risk mucosal human papillomavirus type, usually associated with anogenital and oropharyngeal cancer. This paper describes the first two cases of human papillomavirus 16 and p16 related nasal cutaneous squamous cell carcinoma.

Prospective case series from December 2015.

Two young, male, fair-skinned patients had large (greater than 20 mm), rapidly growing, ulcerated lesions of the nasal tip. The tumours were excised, with at least a 6 mm margin, and the patients' noses were subsequently reconstructed. Neither patient had cervical lymphadenopathy or underwent adjuvant radiotherapy. Both patients were registered at the same general practice. The tumours were human papillomavirus 16 and p16 positive; the latter indicated that the virus was driving the disease process. Except for superficial burns, neither patient had other risk factors.

Changes in sexual practices have led to an increase in human papillomavirus positive oropharyngeal carcinoma and there may be an associated increase in human papillomavirus type 16 positive nasal cutaneous squamous cell carcinoma.