To describe our technical modifications of midfacial translocation for access to the nasopharynx, and anterior, central and lateral skull base.

Retrospective chart review of a prospective case series.

Department of Otolaryngology-Head and Neck Surgery, Aberdeen Royal Infirmary, Scotland, UK.

Along with demographics, other parameters studied were adequacy of exposure, completeness of resection, aesthetic outcome and complications. Our main outcome measures included adequacy of exposure, partial or total resection of tumour, aesthetic outcome, and complications related to surgical technique.

A total of 48 patients underwent modified midfacial translocation at our institution for nasopharyngeal, parapharyngeal, and anterior, central and lateral skull base tumours. In all cases, the exposure was deemed to be adequate. Two patients developed wound dehiscence in previously irradiated fields. Other incisions healed very well and the aesthetic outcome was regarded as satisfactory.

Modified midfacial translocation is based on the principle of temporary craniofacial disassembly for access to the skull base. Our modifications offer adequate access and a better aesthetic outcome. All incisions are placed through the aesthetic sub units of the nose with preservation of the lip. Preservation of the bony piriform aperture prevents airway compromise.

The main purpose of this study was to evaluate the effect of the pectoralis major myofascial flap on pharyngocutaneous fistula formation and time to oral feeding.

This retrospective study reviewed 155 total laryngectomies. Patients were divided into two main groups. Group 1 included 110 patients who were treated primarily by total laryngectomy and group 2 comprised 45 patients who were treated by salvage laryngectomy with or without a pectoralis major myofascial flap.

The use of a pectoralis major myofascial flap did not have a significant effect on pharyngocutaneous fistula formation in the salvage group (p = 0.376). When comparing the oral feeding day of patients with pharyngocutaneous fistula, a significant difference was observed between the salvage group with pectoralis major myofascial flap reinforcement and the salvage group without pectoralis major myofascial flap reinforcement (p = 0.004).

Our study demonstrated that pectoralis major myofascial flap reinforcement did not decrease the rate of pharyngocutaneous fistula formation. Instead, it prevented the formation of large fistulas that would require surgical management, and showed a similar time to oral feeding and length of hospital stay to primary laryngectomy.

‘R staging’ is a new ultrasonographic scoring system developed and used by our specialist head and neck radiologist for reporting sonographic risk of malignancy to those at our thyroid multidisciplinary team meeting. This study aimed to: classify the R staging system, examine its relationship with the eventual histopathological diagnosis and define its clinical utility.

The pre-operative ultrasound scans of 78 patients were assigned an R status by our specialist head and neck radiologist. The final histopathology report for each thyroid nodule was used as the ‘gold standard’ for analysis.

When thyroid nodules were classified as low risk (R stages 1–3) or high risk (R stages 4–5) for malignancy, the sensitivity of R staging was 74.2 per cent and specificity was 80.9 per cent. An R5 status was 100 per cent predictive of malignancy.

Our results compare favourably with other suggested ultrasonographic staging systems for thyroid nodules.

It is common for ENT specialists to be called to neonatal intensive care units to assess neonates with suspected laryngomalacia. At Addenbrooke's Hospital, Cambridge, UK, it is standard practice to initially try to assess the larynx whilst the patient is awake. This can cause the patient to cry and become irritable, and can induce worry in the parents. A literature search revealed that numerous procedures have been successfully performed on neonates and infants whilst they were being pacified.

This paper describes various procedures where pacification has been used effectively. Furthermore, it reports a pacification technique developed for per-oral flexible laryngoscopy in awake neonates and infants.

To review the diagnosis of Munchausen syndrome by proxy, a factitious disorder, in which symptoms are induced or feigned, usually in a child, by the caregiver. The involved caregiver seeks to gain attention or sympathy and often has a psychological need to maintain the sick role. We highlight the diagnostic difficulties and factors that may help with diagnosis in an otolaryngology setting.

We present the case of Munchausen syndrome by proxy presenting with hearing loss in a five-year old boy, who was diagnosed eight years after his initial presentation. A literature review of Munchausen syndrome by proxy cases presenting with ENT symptoms is provided.

Munchausen syndrome by proxy is a diagnosis that otolaryngologists should be aware of, particularly where recurrent or persistent illnesses in children, especially those involving otological symptoms, are refractory to the usual treatments.

The relationship of the recurrent laryngeal nerve to the superior parathyroid gland during consecutive thyroidectomies was prospectively evaluated. When one structure was noted, careful dissection was performed to locate the other structure, to preserve their natural anatomical relationship.

In total, 103 consecutive thyroid lobectomies were performed on 73 patients. The distance from the superior parathyroid gland to the recurrent laryngeal nerve was recorded.

In 88 cases (88.9 per cent), the superior parathyroid gland was identified within 5 mm of the recurrent laryngeal nerve. In 62 cases (62.6 per cent), the gland was within 1 mm of the recurrent laryngeal nerve. The height of the thyroid lobe was positively associated with the distance between the two structures (p = 0.001), as was the incidence of cancer (p = 0.033). The incidence of recurrent laryngeal nerve paresis was less than 4 per cent.

In most cases, the recurrent laryngeal nerve was found in close proximity to the superior parathyroid gland. In a thyroid gland with a large height, or in a cancerous lobe, this relationship is less reliable.

Collagen-covered prostheses can be used as a non-circumferential segmental tracheal replacement. However, the applicability of these implants in young subjects has not yet been reported.

In this experimental, longitudinal study, dogs aged 29–32 days underwent limited segmental tracheal replacement with a polyester prosthesis or were allocated to a control, untreated group. The dogs were evaluated clinically, endoscopically and tomographically for up to one year.

Although there was evidence of tracheal growth in the experimental group, tomographic measurements were significantly smaller in this group than in the control group throughout the observation period. At the end of the study, there was no evidence of implant rejection, stenosis or collapse. Normal respiratory epithelium had grown across the implanted membrane in the experimental group.

The homologous collagen mersylene membrane allowed for limited structural tracheal growth and was functionally integrated into the segmented tracheal wall in growing dogs.

During an endoscopic arytenoidectomy, an intubation tube must be elevated anteriorly with the laryngoscope to ensure an adequate surgical field. This paper describes a new laryngoscope that has a canal along the outer wall of the body and a ridge which runs along the canal.

Ten patients underwent endoscopic total arytenoidectomy using this new laryngoscope and 10 patients underwent the same operation using a regular laryngoscope.

The duration of all operations ranged between 25 and 65 minutes, with a median duration of 42.5 minutes. The median duration with the new laryngoscope was 39 minutes, and that with the regular laryngoscope was 49 minutes; this difference was statistically significant (p < 0.05).

This new laryngoscope shortened the duration of the endoscopic arytenoidectomy and facilitated the procedure by enlarging the surgical field. This new laryngoscope may be a beneficial surgical instrument for posterior endoscopic laryngeal operations.

To explore the treatment outcomes of patients treated with re-irradiation for recurrent or second primary head and neck cancer.

An analysis was performed of 79 head and neck cancer patients who underwent re-irradiation for second primaries or recurrent disease from January 1999 to December 2011.

Median time from previous radiation to re-irradiation for second primary or recurrence was 53.6 months (range, 2.7–454.7 months). Median age at diagnosis of first primary was 54 years. Median re-irradiation dose was 45 Gy (range, 45–60 Gy). Acute grade 3 or worse toxicity was seen in 30 per cent of patients. Median progression-free survival for recurrent disease was 15.0 months (95 per cent confidence interval, 8.33–21.66). The following factors had a statistically significant, positive impact on progression-free survival: patient age of less than 50 years (median progression-free survival was 29.43, vs 13.9 months for those aged 50 years or older; p = 0.004) and disease-free interval of 2 years or more (median progression-free survival was 51.66, vs 13.9 months for those with less than 2 years disease-free interval).

Re-irradiation of second primaries or recurrences of head and neck cancers with moderate radiation doses yields acceptable progression-free survival and morbidity rates.

To assess subjective preference using three nasal hygiene systems: Stérimar Original®, Emcur® and Sinus Rinse™.

We used a prospective, single-blind, randomised, crossover study to compare three nasal hygiene systems: Stérimar Original, Emcur and Sinus Rinse.

Eighteen adult volunteers were recruited and were asked to rate their experience over three days using three well-established nasal hygiene systems. A standard visual analogue scale was used to assess five criteria: (1) simplicity of instructions; (2) ease of use; (3) comfort; (4) perceived nasal clearance (effectiveness) and (5) single best overall system.

Stérimar Original was found to have the easiest instructions to understand compared to the other two systems. There was no significant difference between Stérimar Original and Sinus Rinse with regards to ease of use but they were both significantly easier to use than Emcur (p < 0.05). There was no statistically significant difference between the three systems when comparing the last three criteria. There was no alteration in preference when the cost of each treatment was disclosed to the subjects, and no significant side effects were reported.

The instructions accompanying Stérimar Original appeared to be the easiest to understand, while Stérimar Original and Sinus Rinse were easier to use than Emcur.

To report a case of meningioma arising from the nervus intermedius.

This paper comprises a case report, literature review, and discussion regarding the presentation of a nervus intermedius meningioma, comparing and contrasting this to other relevant neoplasms of the internal auditory canal and cerebellopontine angle.

Tumours of the cerebellopontine angle include vestibular schwannomas, facial schwannomas and, more rarely, nervus intermedius schwannomas. The nervus intermedius is a division of the facial nerve at the cerebellopontine angle, with parasympathetic and afferent somatic components. Our patient presented with progressive hearing loss. An ipsilateral internal auditory canal mass at the fundus, as indicated by magnetic resonance imaging and electroneuronography, was suggestive of vestibular schwannoma. Intra-operative dissection revealed a nervus intermedius tumour. Histological evaluation indicated a meningioma rather than a schwannoma.

This is the first reported case of meningioma involving the nervus intermedius. The implications this pathology may have on surgical approach, facial nerve outcomes, and the need for improved pre-operative imaging and intra-operative monitoring are discussed. A review of the current literature on nervus intermedius tumour is provided.

The prevalence of overweight and obesity is increasing worldwide. The impact of overweight on post-tonsillectomy haemorrhage rates in children and adults is unclear.

Body mass index and post-tonsillectomy haemorrhage were evaluated in all patients treated with tonsillectomy within one year in a tertiary referral centre. Bleeding episodes were categorised according to the Austrian Tonsil Study.

Between June 2011 and June 2012, 300 adults and children underwent tonsillectomy. Post-tonsillectomy haemorrhage occurred in 55 patients. Of those, 29 were type A (history of blood in saliva only, no active bleeding), 15 were type B (active bleeding, treatment under local anaesthesia) and 11 were type C (active bleeding, treatment under general anaesthesia). The return to operating theatre rate was 3.7 per cent. Post-tonsillectomy haemorrhage was more frequent in adolescents and adults than in children. Overweight or obesity was positively correlated with age. Post-tonsillectomy bleeding was recorded in 11.1 per cent of underweight patients, 18.9 per cent of normal weight patients and 18.7 per cent of overweight patients (p = 0.7). Data stratification (according to age and weight) did not alter the post-tonsillectomy bleeding risk (p = 0.8).

Overweight or obesity did not increase the risk of post-tonsillectomy haemorrhage in either children or adults.

Isolated olfactory dysfunction is a common complaint; the vast majority of cases are benign and untreatable. A common dilemma is whether to image the olfactory tract of affected patients.

A case review of 100 consecutive patients who underwent magnetic resonance imaging for the primary complaint of olfactory dysfunction was performed. Patients with a diagnosis of chronic rhinosinusitis, with or without nasal polyps, were excluded.

Magnetic resonance imaging abnormalities that were considered clinically relevant to the presentation of olfactory dysfunction were found in only seven patients (7 per cent). Of these, only one patient (1 per cent) had an abnormality found that altered their clinical management. A comparison of the findings for children (less than 16 years old, n = 5) with those for adults (equal to or more than 16 years old, n = 95) revealed that 4 per cent of adults scanned had olfactory-related pathology diagnosed, as opposed to 60 per cent of children.

Cross-sectional imaging may not be necessary in most patients with olfactory dysfunction. Imaging adds little to the patient history and clinical examination findings.

Tracheostomies are a common procedure within the specialties of otolaryngology and intensive care. The ENT department at Monklands Hospital has developed the position of tracheostomy clinical nurse specialist to improve the management of tracheostomy patients. There is evidence to support the development of a multidisciplinary team for the management of tracheostomy patients following intensive care unit treatment; however, the creation of a specific tracheostomy clinical nurse specialist position has not been widely endorsed in the literature.

This paper describes the role of the tracheostomy clinical nurse specialist, advocating this position within the multidisciplinary team.

Papillary microcarcinoma of the thyroid has been described as either a normal variant or a serious malignancy. We describe our experience with papillary microcarcinoma and lymph node metastases.

A total of 685 consecutive total thyroidectomies with central compartment neck dissection were reviewed for papillary microcarcinoma. Association of central compartment lymph node metastases with age, gender, tumour multifocality, bilaterality and extrathyroidal extension was analysed.

Out of 170 papillary microcarcinoma cases, multifocality was found in 72 (42.4 per cent), bilaterality in 49 (28.8 per cent) and extrathyroidal extension in 16 (9.4 per cent). In all, 23 patients (13.5 per cent) had lymph node metastases. There was a significant association (p < 0.05) between extrathyroidal extension (but no other tumour characteristics) and lymph node metastases.

In all, 13.5 per cent of papillary microcarcinomas in our series showed lymph node metastases. Lymph node metastases were associated with extrathyroidal invasion of the papillary microcarcinoma.

To analyse trends in two-week rule referrals for head and neck cancer over 10 years.

Data from two-week referrals received by the Wirral University Hospital NHS Trust between 1 January and 30 June 2012 were compared with similar data from 2002.

A total of 357 referrals were received during the 6-month audit period, compared with 149 during the whole of 2002. Cancer pick-up rates were 9 per cent and 5 per cent in the first and second cycles, respectively.

The annual number of two-week referrals made to our department increased by over 450 per cent in 10 years, but the resulting cancer pick-up rate fell by nearly 50 per cent. Whilst cancer patients need to be seen quickly, the current system is inefficient in parts. Modifications to the treatment pathway should be considered to improve patient care quality and reduce pressure on ENT departments.

Non-healing ulcers can be caused by a number of conditions, including vascular disease, diabetes, malignancy and some infections. Drug-related ulcers are rare, and a high index of clinical suspicion is required for diagnosis, in parallel with exclusion of more sinister underlying causes.

We present a patient with a complex medical background, who had a 10-week history of a non-healing ulcer on his nasal bridge. Inflammatory, autoimmune and malignant causes for the ulcer were excluded by histopathology.

Nicorandil was deemed to be the most likely cause for the patient's ulcer. Nicorandil is an anti-anginal medication known to cause oral ulceration and skin lesions in the perianal and peristomal regions and around surgical wounds. However, there are no previously reported cases of facial ulcers. The ulcer required surgical debridement and healed completely within six months, following discontinuation of nicorandil. This case highlights the importance of having a high index of clinical suspicion regarding non-healing ulcers, and of considering drugs as an aetiological factor, especially in patients with a complex medical background who are taking numerous medications.

To determine the prognostic value of laryngoscopy in predicting the recovery of unilateral vocal fold paralysis.

A prospective study was carried out of all patients with unilateral vocal fold paralysis without a progressive lesion or arytenoid dislocation.

Among the 66 candidates, 15 recovered. Patients with interarytenoid paralysis (p < 0.001) or posterolateral tilt of the arytenoid (p = 0.028) had less chance of recovery. Among 51 patients who did not recover, 25.49 per cent regained phonatory function by compensatory movement of the normal side; the rest required an intervention. Intervention requirement was significantly less for those patients who had isolated glottic level compensation. The paralysed vocal fold was at the same level in 32.35 per cent of patients, higher in 38.23 per cent and lower in 29.42 per cent. In those in whom vocal folds were in the abducted position (46.67 per cent), the affected vocal fold was at a lower position on phonation. Inter-observer reliability assessment revealed excellent to good agreement for all criteria.

Interarytenoid paralysis and posterolateral tilt of the arytenoid were predictors of poor recovery.