Hyperpneumatisation of the skull base and upper cervical vertebrae is a very rare condition of uncertain aetiology and pathophysiology.

A case of extensive hyperpneumatisation of the craniocervical junction and upper three cervical vertebrae is described, in a patient who habitually performed the Valsalva manoeuvre to relieve the symptoms of a patulous eustachian tube. Reported symptoms of ear, neck and shoulder pain deteriorated after minor head trauma. There was a drastic radiological and clinical improvement after ceasing to perform the Valsalva manoeuvre.

All reported cases of craniocervical bone hyperpneumatisation have in common a history of raised middle-ear pressure, minor trauma or both. We therefore suggest that chronically raised middle-ear pressure leads to destruction of bony tissue and pneumatisation, and that this process is able to cross joints into the cervical spine, either via micro-fractures following trauma, or as a result of congenital assimilation of the craniocervical junction.

We wanted to identify the presentation, diagnostic work-up and treatment outcomes of patients with sinonasal malignancy at Derriford Hospital, Plymouth, UK and compare these with the European Position Paper on Endoscopic Management of Tumours of the Nose, Paranasal Sinuses and Skull Base.

This was a retrospective audit of all patients diagnosed with sinonasal malignancy over a five-year period. The clinical records and picture archiving and communications system data of the patients were reviewed.

Thirty patients with sinonasal malignancy were identified out of 570 head and neck cancer patients. The nasal cavity was the most common site for presentation, followed by the maxillary sinuses. Fifty per cent of patients had a squamous cell carcinoma and 27 per cent had a malignant melanoma. Half of the patients presented at stage IV of the cancer and 20 per cent at stage III. Thirty-seven per cent of patients underwent surgical management and only 20 per cent of the total patient group underwent endoscopic surgery. The mortality in our series was 30 per cent over the studied period.

Late-stage presentation of sinonasal malignancy has resulted in increased patient mortality in our case series. Also, we found a high incidence of malignant melanoma with high recurrence and survival rates.

To assess management of epistaxis at a tertiary ENT referral hospital against a recently published standard of best practice.

Fifty consecutive cases of acute epistaxis that required admission to Guy's Hospital in 2009 were evaluated. Epistaxis education sessions were held to introduce our algorithm of best practice in tandem with an emphasis on emergency department care. Similar retrospective reviews were carried out in both 2010 and 2011 (on groups of 50 patients).

The first audit cycle demonstrated that only 8 per cent of patients underwent a suitable nasal examination in the emergency department prior to transfer, with no documented attempts at nasal cautery. Surgical intervention procedures were performed on only 40 per cent of eligible patients. The audit cycles that followed the introduction of the epistaxis algorithm demonstrated continued improvement in initial evaluation and management of epistaxis. In select patients, sphenopalatine artery ligation can provide timely, definitive management of refractory epistaxis.

Ototoxicity caused by medication can lead to debilitating symptoms such as dizziness, vertigo and postural instability. There is no current ‘gold standard’ treatment available.

A 79-year-old male, with bilateral loss of vestibular function caused by gentamicin toxicity after surgery for prosthetic valve endocarditis, complained of dizziness, difficulty in walking and an increased risk of falling. Physical examination showed a positive head thrust test suggesting bilateral loss of vestibular function.

The patient underwent a specific motion-based virtual reality enhanced protocol for peripheral vestibular disease. He showed a great improvement, with a 50 per cent reduction in his Dizziness Handicap Inventory score.

Computer-aided rehabilitation programmes might represent an important advance in gait and posture training.

Coincident thyroid and head and neck squamous cell carcinomas are rare. This paper presents a case of synchronous laryngeal squamous cell carcinoma, follicular thyroid carcinoma and micropapillary thyroid carcinoma.

A PubMed search was performed for articles describing synchronous thyroid and head and neck squamous cell carcinomas, using the search terms ‘thyroid cancer’, ‘cancer of the head and neck’, ‘synchronous’ and ‘synchronous neoplasm’.

The literature suggests that the head and neck squamous cell carcinoma stage is a better predictor of outcome than the extent of surgical treatment of the thyroid gland in synchronous malignancies.

The decision regarding surgical treatment of the thyroid in synchronous thyroid and head and neck squamous cell carcinomas should take several factors into account. The head and neck squamous cell carcinoma stage is the strongest predictor of outcome, although patient-related factors and the location of malignant thyroid tissue may also affect management.

A bone-anchored hearing aid uses the principle of bone conduction and osseointegration to transfer sound vibrations to a functioning inner ear. It consists of a permanent titanium implant, and removable abutment and sound processor. Informed consent requires discussion of the procedural benefits, alternatives and complications. The risks of bone-anchored hearing aid surgery include infection, soft tissue hypertrophy, skin graft or flap failure, osseointegration failure, and the need for further surgery.

A case of cerebrospinal fluid leak in a patient undergoing bone-anchored hearing aid surgery is reported and discussed.

Bone-anchored hearing aid surgery poses a risk of breaching the inner table of the temporal bone and dura, resulting in a cerebrospinal fluid leak; the risk of meningitis is rare but serious. The surgeon should discuss the possibility of cerebrospinal fluid leak when consenting patients. Pre-operative computerised tomography scanning should be considered in certain individuals to aid implant placement.

To evaluate the safety and effectiveness of radiofrequency dissection in conventional ‘open’ total thyroidectomy.

Thirty-nine patients scheduled for conventional total thyroidectomy were included in a prospective randomised study. Patients were randomly assigned to one of two groups: a radiofrequency dissection method was used in one group, and a knot tying technique was used in the other.

Significantly fewer surgical instruments and materials were required for the radiofrequency dissection group than the knot tying group (p < 0.01). There were no significant differences between the two groups in mean operative time, blood loss, post-operative drainage and pain, recurrent palsy, and hypocalcaemia (p > 0.05).

Radiofrequency dissection is a safe alternative to the knot tying technique, and enables a significant reduction in the number of surgical instruments required for the operation.

This study aimed to describe total volume and cross-sectional area measurement changes in obstructive sleep apnoea patients associated with a supine versus an upright position.

A retrospective chart review of patients who underwent cone beam computed tomography in upright and supine positions was performed, and the images were analysed.

Five obstructive sleep apnoea patients (all male) underwent both upright and supine cone beam computed tomography imaging. Mean age was 35.0 ± 9.3 years, mean body mass index was 28.1 ± 2.7 kg/m2 and mean apnoea–hypopnoea index was 39.3 ± 23.0 per hour. The airway was smaller when patients were in a supine compared with an upright position, as reflected by decreases in the following airway measurements: total volume; posterior nasal spine, uvula tip, retrolingual and tongue base (not significant) cross-sectional areas; and site of the minimum cross-sectional area (of the overall airway). Total airway volume decreased by 32.6 per cent and cross-sectional area measurements decreased between 32.3 and 75.9 per cent when patients were in a supine position.

In this case series, the airway of obstructive sleep apnoea patients was significantly smaller when patients were in a supine compared with an upright position.

Acute respiratory decompensation can occur on a background of slowly progressive airway compromise, for example in laryngeal squamous cell cancer. Surgeons in ENT, together with anaesthetists, are often asked to evaluate airway risk and as yet there is no widely adopted standardised approach.

This paper reports the case of an 82-year-old male, who presented with acute airway compromise due to both endolaryngeal obstruction from a squamous cell cancer and extralaryngeal compression from massive subcutaneous emphysema.

Primary total laryngectomy was performed, but the patient declined adjuvant radiotherapy. He died a year later from a heart attack without evidence of recurrence.

To the best of our knowledge, this is the first case report of acute airway compromise from extralaryngeal subcutaneous emphysema secondary to laryngeal cancer. Options for acute airway management are discussed.

Samter's triad is a well described condition manifesting as chronic rhinosinusitis with nasal polyposis, asthma and aspirin intolerance in a non-atopic individual. The underlying mechanism is still to be fully elucidated. However, aural disease has not been widely reported in these patients. In the few reported cases, most patients underwent major surgery with varying degrees of success.

We report two Samter's triad patients with aural involvement. Both were successfully managed by conservative treatment, thus avoiding the need for major surgery. It appears that more Samter's triad patients may have aural disease than previously thought.

We report good outcomes with conservative treatment, which is relevant because aural disease tends to reoccur in these patients.

To report a case of patulous eustachian tube which occurred after percutaneous balloon microcompression of the Gasserian ganglion.

Retrospective case review.

A 41-year-old man was referred to our audiovestibular medicine department following episodes of autophony. These symptoms appeared two weeks after percutaneous balloon microcompression performed to treat severe trigeminal neuralgia secondary to multiple sclerosis. A diagnosis of patulous eustachian tube was indicated by clinical examination and tympanometry. The symptoms were present for less than six months and improved without any specific treatment.

Percutaneous balloon microcompression is a procedure used for refractory trigeminal neuralgia that can cause transient sensory and motor deficits of any of the trigeminal nerve branches. It is proposed that injury to the mandibular division in this case caused temporary tensor veli palatini dysfunction with consequent patulous eustachian tube.

We report a novel, computed tomography guided treatment for autophony associated with a patulous eustachian tube.

Case report and literature review of the management of patulous eustachian tube.

A 36-year-old woman presented with disabling autophony. Otoscopic examination revealed a poorly mobile right tympanic membrane. High resolution temporal bone computed tomography excluded superior semicircular canal dehiscence. The patient was diagnosed with patulous eustachian tube but failed to achieve therapeutic benefit from conventional endoscopic placement of a silicone elastomer suspension implant adjacent to the eustachian tube. Subsequently, she underwent further silicone elastomer suspension implant placement via a trans-cutaneous, computed tomography guided approach. The patient achieved prompt symptomatic relief and remained symptom-free at six-month follow up.

This is the first published description of treatment of patulous eustachian tube using a computed tomography guided, trans-cutaneous approach. It serves to highlight to otolaryngologists the fact that computed tomography guided treatment of patulous eustachian tube may control disabling symptoms in patients who have failed to respond to convention endoscopic management.

Thyroglossal duct cysts and obstructive sleep apnoea are commonly occurring medical conditions which appear to present independently in patients. However, we noted three cases where the thyroglossal duct cysts influenced the development and/or therapy of obstructive sleep apnoea. In this article, these three case studies are presented, as is a study of the association between thyroglossal duct cysts and obstructive sleep apnoea, preceded by a literature review.

The patient in the first case study underwent hyoidthyroidpexia for obstructive sleep apnoea, which revealed an unexpected thyroglossal duct cyst. The second patient had previously undergone Sistrunk surgery for the removal of a thyroglossal duct cyst and subsequently presented with obstructive sleep apnoea. Finally, the third patient, who had previously undergone Sistrunk surgery, presented with obstructive sleep apnoea and underwent alternative surgery as hyoidthyroidpexia was no longer possible.

To our knowledge, the association between thyroglossal duct cysts and obstructive sleep apnoea has not been addressed previously. The results indicate that the relationship is much stronger than previously thought, and further research is required to investigate the extent of the association and possible causal relations.

To document the use of transmastoid labyrinthectomy in the treatment of disabling vertigo after unilateral cochlear implantation.

A 58-year-old man with severe-to-profound bilateral sensorineural hearing loss secondary to chronic otitis media underwent cochlear implantation in his right ear with a Pulsar Med-El device. The surgery was uneventful and the electrode was positioned correctly. He had episodic vertigo three months after implant surgery, and medical treatment and aggressive vestibular rehabilitation did not relieve the vertigo attacks.

Right transmastoid labyrinthectomy was performed one year after cochlear implantation. The patient's symptoms were immediately relieved, and cochlear implant function was not adversely affected at follow up after three years.

Transmastoid labyrinthectomy seems to be an effective, safe method for ablating the vestibular end organ after unilateral cochlear implantation.

The larynx is an intricate structure serving three important functions in humans: it protects the lower respiratory airway, facilitates respiration and helps produce sound through a key role in phonation.

We report the first published finding of congenital duplication of the larynx in a patient with previously cleared squamous cell carcinoma of the neck and a new diagnosis of squamous cell carcinoma of the lung.

We describe the incidental finding of duplication of the larynx in a 62-year-old man with previously completely cleared squamous cell carcinoma of the neck, who presented with worsening dyspnoea. We also provide a brief overview of other published cases in which duplication of the vocal folds and epiglottis has been reported.

Our patient experienced no symptoms related to this incidental finding of congenital duplication of the larynx.

The first case of congenital duplication of the larynx is currently of academic interest only; however, the possible association with squamous cell carcinoma is postulated to raise awareness in clinicians who may observe further cases in the future.

To describe the clinical features of head and neck tuberculosis in KwaZulu-Natal, South Africa.

Retrospective, observational study.

The study included 358 patients who received a histopathologically and/or microbiologically confirmed diagnosis of tuberculosis in the head and neck region between 1 January 2007 and 31 December 2011.

A total of 358 new cases of head and neck tuberculosis were identified during the study period, involving 196 males (54.7 per cent) and 162 females (45.3 per cent). These patients had a median age of 31 years (range, 3 months to 83 years). Testing for human immunodeficiency virus was positive in 233 (65.1 per cent) and negative in 125 (34.9 per cent). Right-sided cervical lymphadenitis was the commonest form of presentation of head and neck tuberculosis.

In this study, right-sided cervical lymphadenopathy was the commonest presentation of head and neck tuberculosis in both human immunodeficiency virus infected and non-infected individuals. Head and neck tuberculosis should not be excluded solely based on a normal chest X-ray, nor on the absence of constitutional symptoms.

Revision laryngeal framework surgery is usually performed for medialisation laryngoplasty failure, rather than for failure after arytenoid adduction. We describe a new method for revision arytenoid adduction surgery, performed by directly pulling the lateral cricoarytenoid muscle (‘lateral cricoarytenoid muscle pull surgery’).

We describe a case of revision laryngeal framework surgery, present a literature review and describe the advantages of lateral cricoarytenoid muscle pull surgery over the original method of arytenoid adduction using a posterior approach.

Medialisation laryngoplasty combined with arytenoid adduction was performed following unilateral vocal fold paralysis from mediastinal surgery, resulting in severe glottic insufficiency. The patient's voice improved after the initial surgery, but had deteriorated 18 months later. Revision surgery was performed using lateral cricoarytenoid muscle pull surgery, and her voice recovered normally in terms of perceptual impression. The post-operative course was uneventful for 10 months following revision surgery.

To our knowledge, this is the first case of revision arytenoid adduction performed using a lateral cricoarytenoid muscle pull approach. Lateral cricoarytenoid muscle pull surgery should therefore be considered as a new fenestration approach for arytenoid adduction.