Transsexualism is a condition involving a paradoxical feeling of belonging to the opposite sex. Acquiring a sex-appropriate voice is a crucial part of the patient gaining acceptance in their new gender. Speech and language therapists and otolaryngologists play an important role in influencing communication behaviour in transgender patients by altering the fundamental frequency of speech to one acceptable for the patient's sex.

Review of the literature suggests that speech and language therapy is successful at creating an acceptable fundamental frequency in transgender patients, as well as influencing other communication behaviours. Laryngeal surgery, such as cricothyroid approximation, has an important role in raising the fundamental frequency in those who do not achieve acceptable voice via non-surgical means. There is little information on patient satisfaction and quality of life measures. Research is currently underway to explore this aspect further.

Objective: The purpose of this study was to determine the protective effect of edaravone, a free radical scavenger, on inner-ear barotrauma (IEB) in guinea pigs, based on a hypothesis implicating free radicals in the development of IEB.

Materials and methods: One hundred and twenty-five guinea pigs were divided into a control group and a pretreatment group. After auditory brainstem response (ABR) testing, the pretreatment group received 9.0 mg/kg intraperitoneal edaravone. Animals were exposed to pressure loading and then to further ABR testing.

Results: The incidence of IEB was 62.7 per cent in the control group and 42.9 per cent in the pretreatment group (p < 0.01). The distributions of threshold elevation in the control group were 37.3 per cent (for 10 dB or less), 21.3 per cent (for 20–30 dB), 18.0 per cent (for 40–60 dB) and 23.4 per cent (for 70 dB or more), and those in the pretreatment group were 57.1 per cent, 19.1 per cent, 14.3 per cent and 9.5 per cent, for the same respective decibel levels (p < 0.01).

Conclusions: These results suggest that protective treatment with edaravone can significantly reduce both the incidence of IEB and the severity of the resultant ABR threshold elevation.

Objective: To evaluate the prognostic factors in benign paroxysmal positional vertigo (BPPV) treated with canalith repositioning procedures (CRPs).

Material and methods: Retrospective study of consecutive BPPV cases diagnosed over three years. All patients underwent a complete otolaryngologic, audiologic and neurotologic evaluation. The appropriate CRP was performed, depending on the type of BPPV. Prognostic factors studied included age, sex, aetiology, duration of disease, abnormal electronystagmographic findings, canal involvement, improper performance of manoeuvres, response on first or repeat treatment, and presence of recurrences.

Results: One hundred and fifty-five patients were studied, 66 men and 89 women, with mean ages of 58.7 and 60.4 years, respectively. Age and the involvement of two canals or bilateral disease had an effect on initial treatment outcome and were correlated to increased recurrences but not to repeat treatment outcome. Secondary BPPV, abnormal electronystagmographic findings and improper performance of manoeuvres had a significant effect both on initial and repeat treatment, but not on recurrences. Sex and duration of symptoms had no effect.

Conclusion: Canalith repositioning procedures provide fast and long-lasting treatment of BPPV in most patients. However, in a small subgroup of patients, failures may be noticed that may be attributed to various prognostic factors.

Objective: To assess the association between the habitual head position during bedrest and the affected ear in benign paroxysmal positional vertigo (BPPV).

Study design: Prospective trial of patients with active BPPV of the posterior semicircular canal, confirmed on physical examination.

Methods: Seventy-five patients were asked to explain the head position and lying side they were accustomed to before falling asleep in bed.

Results: Fifty patients (67 per cent) habitually adopted a lateral head position during bedrest. The ear affected by BPPV was found to be consistent with the head-lying side during bedrest in 43 cases (86 per cent) (29 cases for the right ear and 14 cases for the left ear).

Conclusion: Habitual lateral head-positioning during bedrest can be a major factor leading to the development of BPPV in the ipsilateral ear.

Objectives: To report the clinical results of a bone-anchored hearing aid (BAHA) programme in a district general hospital, compared with those in an established, large, university teaching hospital centre.

Design: A retrospective postal questionnaire sent to BAHA patients, with two month waiting time and one reminder, combined with case note analysis. Results compared by appropriate statistical tests with published outcomes data from the largest UK series.

Setting: Public sector (National Health Service) district general hospital, England. Catchment population: 300 000 (mixed rural and small towns).

Participants: Case note analysis of sixty-three patients implanted between 1994 and 2003 (age range, six to 88 years). The commonest indication was chronic otitis media, with inability to wear a conventional hearing aid. Otitis externa, otosclerosis and sensorineural hearing loss were other indications. The questionnaire was sent to 59 patients who had worn their aid for at least six months; it was returned by 41 (69 per cent).

Main outcome measures: Glasgow benefit inventory (GBI, change in health status following otolaryngological intervention); incidence of complications.

Results: Bone-anchored hearing aid implantation significantly improved quality of life as measured by the GBI (p < 0.001). The degree of improvement was similar to that achieved in Birmingham by Proops et al. (p > 0.05, chi-squared test). Minor temporary skin infection was common (33 per cent). Thickening of the skin around the implant occurred in 17 per cent. One implant (2 per cent) failed. There were no serious complications.

Conclusion: The BAHA is a safe, reliable and effective treatment for selected patients. A successful BAHA programme can be run in a district general hospital.

Objectives: The aim of this study was to assess the impact on implant survival, abutment skin reaction and patient satisfaction in patients implanted with a bone-anchored hearing aid (BAHA), following the introduction of a multidisciplinary team (MDT) in 1997.

Design and methods: Part prospective and retrospective analysis. Implant survival and cause of failures were recorded along with abutment skin reaction (graded as none, mild, moderate and severe, according to the amount of wound care required). Patient satisfaction and quality of life were assessed using a questionnaire enquiring about several aspects of the use and benefits of their BAHA.

Setting and participants: Eighty patients treated at the Bradford Royal Infirmary between 1991 and 2005. The unit is a recognized tertiary referral centre.

Results and conclusions: Twelve out of 80 implants failed, giving an overall failure rate of 15 per cent. Kaplan–Meier survival curves show a steady decrease in implant survival. The MDT had a positive effect on implant survival and adverse skin reactions, with a higher proportion of patients experiencing no reaction after its introduction. There was a 92.5 per cent response rate to the questionnaire. Overall patient satisfaction was high, both before and after the introduction of the MDT.

Objective: We report our technique and results for endoscopy-aided CO2 laser therapy for the treatment of intractable granular myringitis, as an out-patient office procedure.

Materials and methods: A total of 21 patients (14 women and seven men; mean age 32.6 years) were retrospectively reviewed, all of whom suffered from intractable granular myringitis and had undergone endoscopy-aided laser treatment. Granulation tissue was vaporized for one to two seconds with a CO2 laser (spot size 0.5–1 mm with a power setting of 5–10 W in continuous mode). The mean follow-up period was 11 months.

Results: Eighteen of the 21 patients (85 per cent) were cured after a single treatment. Three patients with the diffuse form of the disease required repeat laser treatments coupled with self-irrigation with a diluted vinegar solution. We noted no perforations of patients' tympanic membranes after laser vaporization. We also observed no recurrences over follow-up periods ranging from three months to 2.6 years. Our laser procedure produced no adverse effect on hearing thresholds, nor were any other complications observed.

Conclusion: Our results suggest that endoscopy-aided CO2 laser ablation is a reliable and minimally invasive method associated with low rates of recurrence and a low incidence of complications. It can be conducted as an office procedure.

Introduction: Otitis media with effusion (OME) is an inflammation of the middle ear in which a collection of liquid is present in the middle-ear space while the tympanic membrane is intact. The association between adenoid inflammation and OME has long been noted but the exact mechanism is still much debated. We studied the role of adenoid mast cells in the causation of OME.

Objective: To study the distribution and role of adenoid mast cells in the causation of OME

Methodology: A cross-sectional, prospective study was carried out in the otorhinolaryngologic clinic, department of otorhinolaryngology (ORL), Science University of Malaysia, from June 1999 to September 2001. A total number of 50 cases were studied. Twenty-five of these patients underwent adenoidectomy, while another 25 patients underwent adenoidectomy and myringotomy with ventilation tube insertion. The adenoid specimens from all patients were examined for the number of adenoid mast cells present, using light microscopy and toluidine blue as the staining agent. The results were analysed using SPSS version 10.0 computer software.

Result: The population of adenoid mast cells in children with OME was significantly greater than that in children without OME (p = 0.000).

Conclusion: The increased number of adenoid mast cells in patients with OME suggests that inflammation may play a role in this condition.

Objective: To investigate the efficacy of intralesional cidofovir in the treatment of recurrent respiratory papillomatosis (RRP) in children.

Methods: Prospective observational study of four consecutive children with RRP treated at an academic tertiary children's hospital. Laryngo-bronchoscopy was performed at three- to five-weekly intervals. Photodocumentation was obtained and disease severity assessed using an anatomical RRP severity score. Surgical debulking of large papillomas was then performed, and cidofovir (5 mg/ml) injected into any remaining papillomas as well as submucosally at the sites of resected papillomas. The efficacy of cidofovir was assessed by the change in papilloma severity score over the course of the treatment.

Results: Complete disease remission was obtained in one patient, with a partial response seen in two others. One patient showed no significant response. The greatest beneficial effect was seen after the fourth cidofovir injection; however, two patients demonstrated a deterioration in severity scores after treatment was withheld at this point. Both responded well to further cidofovir injections. However, a clear plateau in the response to cidofovir was seen in all patients by the eighth injection.

Conclusion: Intralesional cidofovir may help control papilloma regrowth and reduce disease severity in many children with RRP. In most cases, cidofovir would appear to be less efficacious in causing disease eradication. There appears to be little evidence to support prolonged treatment regimes (i.e. more than eight treatments).

Recurrent laryngeal nerve paralysis is a much-dreaded complication of thyroid surgery.

Objective: To study the feasibility and the reliability of a recurrent laryngeal nerve monitoring technique.

Materials and methods: This was a prospective study including 36 patients proposed for thyroid surgery with recurrent laryngeal nerve monitoring. They underwent post-operative fibre-optic laryngeal examination and speech therapist consultation.

Results: Our technique of nerve monitoring showed a 98 per cent sensitivity and 86 per cent specificity.

Conclusions: Recurrent laryngeal nerve monitoring is a feasible and reliable technique. It can be used to avoid bilateral nerve injury and to increase the surgeon's confidence but not to replace a systematic nerve identification and a careful dissection.

Objective: To compare the estimated effects of conservative surgery to those of a mandibular advancement splint (MAS) in the treatment of habitual snoring.

Method: Prospective, observational, non-randomized cohort study.

Results: Adequate follow-up data were available for 88 participants (23 following coblation, 65 after provision of an MAS). The mean reduction in snoring symptoms inventory (SSI) score for the 23 subjects undergoing coblation was 9.83 (± standard deviation 11.43). Reported pain duration was greatest with uvula amputation, but uvula coblation did not always adequately reduce its bulk. Of the 65 MAS patients, 39 (60 per cent) used the device regularly, with a mean fall in SSI of 12 (±16.4, p = 0.001). Approximately one in four patients in both groups achieved a significant fall in SSI (>15 points), and the measured effect sizes were close to 0.75 for both treatments.

Conclusions: Mandibular advancement splints and coblation have similar efficacies. However, their efficacy does not match that of radical surgery.

We present a series of four patients presenting with symptoms leading to a provisional diagnosis of globus pharyngeus. On further investigation, they were all found to have small areas of abnormal mucosa in either their hypopharynx or proximal oesophagus, which on biopsy were reported as containing gastric-type mucosa. Following anti-reflux treatment, all patients eventually reported a cessation of symptoms. All but one patient was followed up with repeat endoscopies. We highlight the fact that biopsies reporting gastric epithelium at this anatomical site are in keeping with the diagnosis of heterotopic gastric mucosa. We review the literature and report the high incidence and natural history of this condition.

Heterotopic gastric mucosa can only be diagnosed on endoscopy and is easily missed, even during such an investigation. We raise the question of whether this condition may be one of a number of factors in the aetiology of globus pharyngeus.

The biological changes in recurrent laryngeal cancer following radiotherapy are not fully understood. The authors investigated differences in the expression of p53, proliferating cell nuclear antigen (PCNA) and bcl-2 in laryngeal cancer specimens before radiotherapy and in recurrent laryngeal cancer specimens following radiotherapy in the same patients. The authors investigated the expression of p53, PCNA and bcl-2 by immunohistochemical stain in 30 specimens from 15 patients with primary laryngeal cancer and recurrent laryngeal cancer after radiotherapy.

The expression of p53 protein was significantly different in laryngeal cancer before radiotherapy (4/15, 26.7 per cent) compared with recurrent laryngeal cancer after radiotherapy (8/15, 53.3 per cent) (p < 0.05). The PCNA index was also significantly different in laryngeal cancer specimens before radiotherapy (mean, 11.9 per cent) compared with recurrent laryngeal cancer after radiotherapy (mean, 18.0 per cent) (p < 0.05). However, there was no statistically significant alteration of bcl-2 expression in primary compared with recurrent laryngeal cancer. The expression of p53 and PCNA increased in recurrent laryngeal cancers after radiotherapy, compared with that in laryngeal cancers before radiotherapy. Recurrent laryngeal cancers arising following radiotherapy became biologically aggressive.

Implementation of the European Working Time Directive and the Modernising Medical Careers initiative will mean junior surgeons must be trained in fewer hours over a shorter period. For this reason, junior surgeon training opportunities must be optimized. We undertook a departmental audit to identify where opportunities to train senior house officers (SHOs) in theatre were being lost, so that appropriate timetable changes could be made in order to optimize exposure to suitable surgical cases. During the first audit cycle, the SHOs followed their existing timetable and theatre attendance was monitored prospectively over a two-week period. Only 30 per cent of theatre sessions were attended and case participation was only 27 per cent. Simple timetable changes were made to maximize SHO theatre attendance, and a second prospective two-week audit was undertaken. The new rota yielded 46 per cent theatre attendance and 48 per cent case participation.

Background: The implementation of the European working time directive has led to an increase in cross-speciality out-of-hours cover. This survey illustrates ENT out-of-hours cover arrangements and assesses the implications for senior house officers (SHOs) responsible for managing emergencies.

Methods: A telephone survey of 100 ENT departments was conducted, asking the on-call SHO about departmental structure, on-call rota design, their previous ENT experience, access to SHO training and their confidence in managing emergencies.

Results: 44 per cent of departments used only ENT SHOs on the on-call rota. 73 per cent always had an ENT middle grade on call. In 60 per cent of hospitals, the ENT consultant was sometimes on call with only a non-ENT SHO. At the time of the study, 5 per cent of SHOs had no ENT experience, no access to training, were not confident in managing simple emergencies and were on-call without middle-grade cover.

Conclusion: The current junior on-call structure for ENT has implications for patient management.

This article presents a combined approach to the nasopharynx, which has not been previously described. The technique is applicable to cases of recurrent nasopharyngeal carcinoma which exhibit lateral extension. We describe the technique and report a case in which it was used. A review is presented of all other techniques currently described. The authors would not advocate the use of a combined approach to the nasopharynx in all cases, but there certainly appears to be a place for this technique.

Keloid scarring is a benign hyperproliferation of fibrous tissue occurring at a wound healing site. Keloid formation related to the ear is generally the result of ear-piercing, mainly causing cosmetic disfigurement. We present an unusual case of keloid formation at a previous meatoplasty incision scar in a 10-year-old Caucasian with a modified radical mastoid cavity. This lesion prevented the cavity from self-cleaning and obstructed microscopic evaluation of the cavity. Treatment was successfully performed by surgical excision, with closure of the defect using supra-keloid skin flaps, followed by serial steroid injection therapy.

Inverted papilloma is a rare, benign tumour representing only 0.5 to 4 per cent of all sinonasal neoplasms; its involvement of the middle ear is extremely rare. We present a case of multicentric inverted papilloma in the sinonasal region and middle ear in a 54-year-old man. The patient later developed neck metastasis secondary to malignant transformation of the inverted papilloma in the middle ear.

We report a case of upper airway obstruction following high-pressure water jet injury to the pharynx incurred from a car wash jet. Injuries from high-pressure water jets are relatively rare and, to the best of our knowledge, airway obstruction as a result has not been reported. Since this unusual injury may be associated with life-threatening complications, it must be promptly recognized and treated.

We describe three homosexual men presenting to the ear, nose and throat clinic with severe tonsillitis. All were subsequently diagnosed with secondary syphilis of the tonsil. Syphilis should be considered as a diagnosis in high risk patients presenting with tonsillar lesions, even in the absence of other classical features of the disease.