Total laryngectomy is a recognised treatment for advanced laryngeal carcinoma. Traditionally, pharyngeal repair is performed with layered sutures. We describe our experience with a technique of closed pharyngoplasty using a linear stapler device.

Ten total laryngectomies were performed from July 2002 to July 2004, using an Ethicon TLC 75 linear stapler for pharyngeal closure. Data collected included age, sex, staging, endoscopic assessment, surgical margins and post-operative course (including complications and swallowing).

Patients comprised eight men and two women. The mean age was 55.4 years. Six patients had stage T4 endolaryngeal carcinoma and four had stage T3. Four patients underwent pre-operative radiotherapy. Clear surgical margins were achieved in all patients. One patient developed a pharyngocutaneous fistula. Patients resumed oral intake at 48 hours, or at 72 hours if they had undergone pre-operative radiotherapy. Patients' mean hospital stay was seven days.

This stapled closed technique for pharyngoplasty is efficient and eliminates the risk of wound contamination, thus theoretically reducing the risk of tumour seeding. In addition, we were able to commence patients on oral fluids at a mean of 48 hours after surgery. The mean hospital stay was seven days. We recommend this technique as an alternative for repairing the pharynx in patients undergoing total laryngectomy for endolaryngeal carcinoma.

We report a histologically proved case of lymphangiomatosis of the skull, involving the temporal bone and presenting as multiple lytic bone lesions.

A case report and a review of the literature concerning lymphangiomatosis are presented.

Lymphangiomatosis affecting bones is a rare disorder caused by a congenital malformation of the lymphatic system, resulting in diffuse proliferation of the lymphatic channels and involving bones, parenchymal organs and soft tissue. Involved bones show massive osteolysis and progressive, localised bone resorption.

Lymphangiomatosis should be kept in mind in the differential diagnosis of lytic lesions of the skull.

To report a series of 53 cases of facial schwannoma, to review the current literature, addressing contentious issues, and to present a management algorithm.

Retrospective case review combined with review of current literature.

A review of the case notes of 53 patients with intracranial and intratemporal facial schwannoma, from two tertiary referral centres, was undertaken. This represents the largest series of facial schwannomas with clinical correlations in the literature. Data relating to epidemiological, clinical and management details were tabulated and compared with other large series. A review of the current literature was performed, and a management algorithm presented.

There were 23 (43 per cent) female and 30 (57 per cent) male patients. Patients' ages at presentation ranged from five to 84 years, with a mean of 49 years. Twenty-five (47 per cent) of the tumours were present on the left side and 28 (53 per cent) on the right side. Hearing loss was the most common presenting symptom, being present in 31/53 (58 per cent) patients, followed by facial weakness in 27/53 (51 per cent). Two patients (4 per cent) were completely asymptomatic, and their facial neuromas were diagnosed incidentally. The schwannoma extended along more than one segment of the facial nerve in 39 patients (74 per cent), with the mean number of segments involved being 2.5. A conservative approach of clinical observation was undertaken in 20 patients (38 per cent). Thirty-three patients (62 per cent) underwent surgery, with a total of 36 procedures. The translabyrinthine approach was most common, being utilised in 17 of the 36 procedures. Two patients underwent revision surgery for residual or recurrent disease on three occasions. There was total removal of tumour in 21 cases; the remainder had subtotal or no removal with drainage or decompression of the tumours. Twenty-one nerve reconstructions were performed, and 18 facial rehabilitation procedures were performed on 14 patients.

The results of this case series are similar to those of other reported series. The diagnosis of facial schwannoma is now generally made pre-operatively, due to improved imaging techniques and heightened awareness. Clinical assessment of facial function and imaging form the mainstays of surveillance for these tumours. These tumours are managed via clinical observation or surgical intervention; the latter can range from simple procedures (such as drainage of cystic components) to aggressive tumour removal and facial nerve reconstruction. Facial rehabilitation procedures may also be applied. The timing of intervention is contentious; surgical intervention is indicated when facial function deteriorates to a House–Brackmann grade IV level.

Facial schwannomas are rare lesions, and reported series are generally small. Due to the complex management issues involved, these tumours are best managed in a tertiary referral setting. Observation is preferred until facial function deteriorates to a House–Brackmann grade III level, at which time surgery is considered. When facial function deteriorates to House–Brackmann grade IV, surgical intervention is indicated. We advocate surgical management based on the treatment algorithm described.

The ototoxic effects of cisplatin include loss of outer hair cells, degeneration of the stria vascularis and a decrease in the number of spiral ganglion cells. Scanning microscopy has shown balloon-like protrusions (blebs) of the plasma membrane of inner hair cells following cisplatin administration. The present study was undertaken to identify the possible role of inner and outer hair cell blebs in the pathogenesis of cisplatin-induced ototoxicity.

Twenty-five guinea pigs were injected with cisplatin and their hearing tested at different time-points, before sacrifice and examination with scanning electron microscopy.

Seven animals showed blebs in the inner hair cells at different stages. Hearing thresholds were lower in animals showing blebs.

Cisplatin seems to be able to induce changes in inner hair cells as well as in other structures in the organ of Corti. Blebbing observed in animals following cisplatin administration could play a specific role in the regulation of intracellular pressure.

The aim of this study was to present the management and survival data of patients with squamous cell carcinoma of the temporal bone, and to discuss whether extensive surgery improves survival.

Retrospective, case-series review of 17 patients (18 cases) with temporal bone carcinoma (15 primary and three recurrent tumours), over a period of 20 years.

Tertiary referral centre – university hospital.

Disease-specific and overall five-year survival.

The mean age at presentation was 63 years, with a range of 39 to 75 years. Twelve cases of de novo tumour were managed by surgical resection followed by adjuvant radiotherapy in 10 cases, while three such patients were considered incurable from the outset and were given a combination of radiotherapy and chemotherapy. Of the three patients referred to our unit with recurrent disease, two were treated elsewhere with radical mastoidectomy and one with chemoradiation; all were subsequently managed by subtotal petrosectomy. The disease-specific and overall five-year survival for the entire cohort was 64.17 per cent (mean 89 months; 95 per cent confidence interval, 62–117) and 47.06 per cent (mean 70 months; 95 per cent confidence interval, 43–98), respectively. The disease-specific and overall survival for patients with advanced T3 and T4 tumours was 59 per cent (mean 83 months; 95 per cent confidence interval, 53–113) and 40 per cent (mean 62; 95 per cent confidence interval, 33–91 months), respectively. All but one recurrence developed within 12 months of initiating treatment. No deaths occurred after 26 months of follow up.

A lateral temporal bone resection is adequate treatment for T1 and T2 tumours. Post-operative radiotherapy should probably be offered for large T2 tumours. For T3 and T4 tumours, a subtotal petrosectomy with parotidectomy followed by post-operative radiotherapy is adequate treatment, as it offers a similar outcome to that of more extensive procedures.

To explore the prevalence and severity of external auditory exostoses in a population of experienced breath-hold divers, and to compare these to the same parameters within surfing and self-contained underwater breathing apparatus diving populations.

A stepwise, multiple regression analysis of cross-sectional data examining the relative contributions of sea surface temperature, latitude of exposure and years of exposure to the prevalence and severity of stenosis due to external auditory exostoses. A chi-square analysis of the prevalence and severity of external auditory exostosis stenosis in the breath-hold divers was compared with previously published data for surfers and self-contained underwater breathing apparatus divers.

Seventy-six male and thirty-five female breath-hold divers attending an international ‘freedive’ competition completed a questionnaire describing aquatic sports habits, geography of participation and symptomatology. Those completing the questionnaire (111/154 attendees) were examined otoscopically for evidence of external auditory exostoses. Images were digitally recorded, scored and graded.

Exostoses were evident in 87.7 per cent of the 204 ears scored and graded for severity of stenosis due to external auditory exostoses. The prevalence of exostoses was no different from that found in previous studies of surfers and self-contained underwater breathing apparatus divers (p = 0.101). However, the pattern of affliction was more similar to that found in surfers. The severity of exostoses was significantly less than that found in surfing populations (p ≤ 0.001 to 0.007), but greater than that found in self-contained underwater breathing apparatus diving populations (p ≤ 0.001). Sea surface temperature at the location of open-water exposure was the most significant predictor of the prevalence and severity of external auditory exostoses in breath-hold divers (p = 0.019).

The prevalence and severity patterns of stenosis due to external auditory exostoses in breath-hold divers are more similar to previously published results for surfing populations than to previously published results for self-contained underwater breathing apparatus diving populations. In breath-hold divers, sea surface temperature is the strongest predictor of severity of stenosis due to external auditory exostoses.

Retrospective.

Among 963 cases undergoing revision mastoid surgery, 13 patients suffered brain herniation. These cases were identified and analysed.

All 13 patients' initial diagnosis was chronic suppurative otitis media with cholesteatoma, and all had undergone previous mastoid surgery resulting in a defect in the tegmen and weakening of the dura mater. The revision procedures performed included 10 (76.9 per cent) modified radical mastoidectomies without ossicular chain reconstruction and one (7.6 per cent) modified radical mastoidectomy with ossicular chain reconstruction; two (15.3 per cent) patients required a blind sac closure. Brain herniation and/or cerebrospinal fluid leak were repaired by a transmastoid ± minicraniotomy procedure.

Injury to the tegmen and dura should be avoided during surgery for chronic middle-ear disease. Cerebrospinal fluid leaks, if encountered, should be managed in the same surgical session. The transmastoid approach is helpful in repairing defects smaller than 1 cm in diameter, whereas the combined transmastoid-minicraniotomy approach provides good access when closing defects larger than 1 cm in diameter and also enables auto-calvarial grafting.

To investigate methods of treating diffuse osteoradionecrosis of the temporal bone in cases of nasopharyngeal carcinoma, following radiotherapy.

Retrospective.

Fourteen post-irradiation nasopharyngeal carcinoma patients (n = 14 ears) with diffuse osteoradionecrosis received surgical treatment from March 1994 to May 2005. The patients underwent radical mastoidectomy (five ears), extensive radical mastoidectomy (one ear), or radical mastoidectomy and obliteration with local vascularised fascia flaps (eight ears).

Six ears fully recovered; two ears were still infectious but sequestrum had not re-formed; five ears (50 per cent) still had repeated suppuration and did not epithelialise; and one ear had local re-formation of sequestrum requiring periodic dressing changes.

Diffuse osteoradionecrosis of the temporal bone following radiotherapy for nasopharyngeal carcinoma is difficult to treat surgically. The main objective of surgery is to facilitate drainage and to prevent complications. Radical mastoidectomy and obliteration with local vascularised flaps is an effective method.

To determine the impact of a patient's gender on the clinical presentation of chronic rhinosinusitis with and without nasal polyposis.

Prospective study of 514 adult patients who presented with chronic rhinosinusitis with and without nasal polyposis. The patients were divided into two groups based on gender: female (n = 273) and male (n = 241). The following data were collected: presenting symptoms, co-morbidities, nasal endoscopy and sinus computed tomography findings, diagnosis, and outcome of surgery. Statistical analysis was performed using the chi-square test, with statistical significance set at p < 0.05.

Facial pain and headache were more prevalent among women, while nasal obstruction was more prevalent among men (p < 0.05). There was no statistically significant difference in the prevalence of environmental allergy, asthma, psychiatric illness or anatomical variants obstructing the osteomeatal unit, comparing the genders. Chronic rhinosinusitis without polyposis was the more common diagnosis among women, while chronic rhinosinusitis with polyposis was the more common diagnosis among men (p < 0.05). Following surgery, a higher percentage of male patients reported improvement in nasal obstruction (p < 0.05), but there was no statistically significant difference in the improvement of the other presenting symptoms, comparing the genders.

Women who suffer from chronic rhinosinusitis are more likely to complain of facial pain or headache on presentation and to be diagnosed with chronic rhinosinusitis without polyposis. On the other hand, men are more likely to complain of nasal obstruction, to be diagnosed with chronic rhinosinusitis with polyposis, and to report improvement in nasal obstruction following surgery.

To evaluate the efficacy of endoscopic exposure and excision for juvenile nasopharyngeal angiofibroma.

Prospective analysis of the outcomes of endoscopic removal of the angiofibroma at a tertiary care centre, using endoscopic and radiological parameters.

Twenty-eight consecutive patients with angiofibroma were included. These patients underwent endonasal endoscopic excision of the lesion, following pre-operative computed tomography and digital subtraction angiography. Post-operative endoscopy and radiology were performed at six weeks to detect any residual lesion, and thereafter at six-monthly intervals to detect recurrence.

Twenty-one patients (75 per cent) were new cases and seven patients (25 per cent) had recurrent tumour. Pre-operative embolisation was performed in 21 patients (75 per cent). An endoscopic endonasal approach was used to access the pterygopalatine fossa. The average blood loss was 228 ml. Residual lesion was noted in one patient (initially with recurrent stage II C pathology). The remaining 27 patients (initially with stage I, II A and II B pathology) were free of residual pathology or recurrence after a minimum follow-up period of 12 months.

Endoscopic exposure and excision of angiofibroma was found to be effective.

Many surgical and nonsurgical procedures have been designed for the treatment of snoring due to palatal flutter. All work in some, but not all, snorers. The difficulty lies in making the definitive diagnosis of palatal flutter as the cause of snoring, and in deciding which patients should undergo which treatment, which in some cases are relatively radical.

This study aimed to assess the usefulness of injection snoreplasty in differentiating palatal flutter from other forms of snoring. This was done in the hope of determining which patients would benefit from definitive palatal surgery such as uvulopalatopharyngoplasty and laser-assisted uvuloplasty.

Sixty consecutive patients referred for habitual snoring were treated with sodium tetradycil sulphate during their first consultation visit. No patients were excluded and none refused the treatment. Forty patients received a single 1 ml dose of 1 per cent sodium tetradycil sulphate, and twenty patients received a single 1 ml dose of 3 per cent sodium tetradycil sulphate under topical anaesthesia. Visual analogue snoring scales were completed by the patient and their partner six weeks, three months, six months and 12 months after the procedure.

Forty of the 60 patients showed improvement in snoring and therefore were considered for definitive surgery. Four of the 60 patients found the investigation unpleasant and did not want any further treatment. Of the 40 patients who showed improvement, 29 maintained this at one year. The other 11 underwent uvulopalatopharyngoplasty or laser-assisted palatoplasty. All patients had successful snoring scale outcomes following the surgery.

A significant number of the patients, 62 per cent, were demonstrated to have significant improvement in the short term. Single dose injection snoreplasty seems not only to be an effective investigation but may constitute a safe and simple treatment within the clinic. At the very least, patients in whom the palate appears not to be the problem are prevented from undergoing painful, unpleasant surgery. Our results support the use of injection snoreplasty, both as an investigation and in some patients as a treatment, for habitual snoring.

To evaluate the efficacy of ultrasonic shear (‘harmonic scalpel’) thyroidectomy, compared with conventional thyroidectomy.

Prospective, case–control comparison.

Twenty-three consecutive patients were recruited over an eight-month period. Patients were divided into two groups according to their thyroidectomy technique, i.e. ultrasonic shear technique (harmonic scalpel) vs conventional technique (scalpel and bipolar diathermy). Surgical time, thyroidectomy type and thyroid specimen weight were recorded by theatre nursing staff. The ratio of surgical time to specimen weight, in minutes per gram, was used to measure surgical efficiency. The unpaired Student's t-test was used for statistical analysis.

The mean surgical time per specimen unit weight was 2.56 min/g for harmonic scalpel thyroidectomy and 5.99 min/g for conventional thyroidectomy. This difference was statistically significant (p = 0.037). The difference was most evident for procedures involving smaller thyroid glands.

Our study suggests that thyroidectomy using a harmonic scalpel is more time-efficient than conventional thyroidectomy, especially when operating on smaller thyroid glands.

To determine the effect of tonsillectomy on morbidity in patients listed for tonsillectomy.

Questionnaire survey of 257 children and 159 adults who had been listed for tonsillectomy. The cohort studied had experienced delays of greater than 12 months between being listed for tonsillectomy and undergoing surgery. They had responded to an earlier questionnaire in 2003 regarding morbidity experienced while waiting for surgery. The same questionnaire was presented to them again in 2005. Morbidity experienced in 2003 was compared to that experienced in 2005 in subjects who had and had not proceeded to surgery in the interval.

Forty-seven per cent of the cohort had undergone tonsillectomy. The questionnaire response rate was 48 per cent. Respondents reported less morbidity in 2005 than in 2003, whether or not they had had surgery. Respondents who had undergone tonsillectomy reported significantly greater reductions in morbidity than those who had not. Five per cent of children who had undergone tonsillectomy experienced at least three short episodes of tonsillitis in the six months before the questionnaire, compared with 35 per cent of those who had not undergone tonsillectomy (p < 0.001).

The morbidity reported by patients suffering from chronic, untreated tonsillitis decreases with time. Tonsillectomy produces significantly greater reductions in morbidity than time alone.

Obstructive adenoid enlargement is commonly implicated as the major cause of chronic nasal obstruction in children. Although clinical assessment is considered essential, there is little consensus over its reliability. This study was conducted to determine the correlation between graded symptomatology assessment and roentgenographic assessment of adenoidal obstruction.

Symptoms assessed included snoring, mouth-breathing and obstructive breathing during sleep. Each symptom was rated on a four-point scale (absent = zero, mild = one, moderate = two and severe = three). We summed the ratings for each child to obtain the symptomatology score. We used an adenoidal–nasopharyngeal ratio parameter to classify roentgenographic assessment into minimal, moderate or marked obstruction.

Sixty-four children, 42 boys and 22 girls, aged one to 12 years were enrolled. The clinical symptomatology scores correlated significantly with the roentgenographic ratings of nasopharyngeal airway obstruction (r = 0.419; p = 0.001). The correlation was significant at roentgenographic ratings of minimal obstruction (p < 0.05) and gross obstruction (p < 0.001). Both the symptomatology score and the roentgenographic rating showed significant correlations with patient age (r = −0.657, p < 0.01 and r = −0.340, p < 0.01, respectively).

Clinical rating of adenoidal symptoms in children provides a reasonably reliable assessment of the presence and severity of nasopharyngeal airway obstruction. This technique of assessment is easy to use and is particularly valid when obstruction is either minimal or gross.

To assess benefit from one and three months' empirical proton pump inhibitor treatment in patients with suspected laryngopharyngeal reflux, and to define pre-therapy factors which may predict success with short-term proton pump inhibitor treatment.

Prospective, open clinical study.

One hundred adult out-patients with suspected laryngopharyngeal reflux were enrolled in the study. Laryngopharyngeal reflux patients underwent endoscopy and received omeprazole for three months. Efficacy of treatment was assessed at one and three months. Patients were classified as responders if their total symptom score had improved at least 50 per cent, their videolaryngoscopic score had improved by at least two points, and they were satisfied with the results. Pre-therapy factors assessed for an effect on omeprazole outcomes included: patient demographics, reflux symptoms, videolaryngoscopic scores, endoscopic findings, overall vocal dysfunction degree, self-rated voice handicap index, hospital anxiety and depression scale scores, and general well-being score.

Fifty-six per cent of patients were classified as responders at one month of treatment; this proportion rose to 92 per cent at three months. Those patients entering the study with a higher heartburn score showed a significant response after one month of omeprazole treatment. Non-responders were found to have significantly more anxiety than responders. Logistic regression analysis revealed these factors, plus the medication dose, as being relevant for faster response prediction. No significant association was found between pre-therapy factors and three-month response to proton pump inhibitor treatment.

Three months of proton pump inhibitor treatment twice daily is warranted for confirming suspicion of laryngopharyngeal reflux. Baseline anxiety levels and heartburn scores, and the medication dose, may be relevant factors when predicting faster response to proton pump inhibitor treatment in carefully selected patients.

To investigate the potential role of caspase-3 and caspase-8 protein expression in the biological behaviour of tongue squamous cell carcinoma.

We conducted immunohistochemical analyses of 87 specimens of primary tongue squamous cell carcinoma, using monoclonal anti-caspase-3 and anti-caspase-8 antibodies. A digital image analysis assay was also performed in order to evaluate the results.

Reduced expression of caspase-8 and -3 proteins was observed in 30/87 (34.5 per cent) and 79/87 (90.5 per cent) cases, respectively. Cox regression analysis showed no prognostic significance for the association between overall protein expression of either marker and survival probability (p = 0.174 for caspase-3; p = 0.608 for caspase-8). Interestingly, the size of the examined tumours was strongly correlated with survival status (p = 0.024).

Simultaneous deregulation of caspase-8 and -3 is a frequent event in tongue squamous cell carcinoma. Activation of caspase-3, which is predominantly down-regulated, may be a crucial process for induction of apoptosis and response to therapeutic strategies.

The management of advanced laryngeal cancer has evolved in the last century, from total laryngectomy to chemoradiation. The aim of this study was to examine our experience with supracricoid partial laryngectomy as a possible solution for patients with advanced laryngeal tumours, with a focus on the oncological safety of the procedure and the functionality of the preserved larynges.

We reviewed the medical records of patients with laryngeal cancer who had undergone primary or salvage supracricoid partial laryngectomy at our department between 1998 and 2004.

Twenty-three patients treated with supracricoid partial laryngectomy for endolaryngeal squamous cell carcinoma were identified. Median follow-up time was 35 months. Twelve patients had advanced laryngeal tumours. Eight patients were radiation failures. These factors were not associated with increased local recurrence or with decreased survival.

Supracricoid partial laryngectomy appears to be a feasible option for the treatment of laryngeal tumours, even in the advanced stage or after failure of radiation therapy.