Vertigo is caused by unilateral vestibular dysfunction. Unilateral vestibular dysfunction represents either vestibular overactivity as benign positional vertigo or underactivity as in labyrinthitis or both, at different times, as in a Ménière's attack. Unilateral dysfunction could also be central rather than peripheral, such as in a lateral medullary syndrome. Unilateral vestibular dysfunction could affect any of the five different sensory areas in the labyrinth, the three semicircular canals and the two otoliths, or their brainstem connections. For rigorous diagnosis of the cause of vertigo, ideally one would have robust, reproducible, quantitative vestibular function tests sensitive to dysfunction of each of the five sensory regions in each ear. In working towards this ideal we have, over the last 15 years, developed three new vestibular function tests: (1) impulsive tests of individual semicircular canal function, (2) evoked potential tests of saccular function and (3) subjective visual horizontal tests of utricular function. The physiological rationale of these three tests is reviewed as well as the interpretation of their results in various diseases.

The relatively new technique of endoscopic stapling in the surgical management of pharyngeal pouch has gained widespread popularity over the last few years. The technique seems to be the procedure of choice as it is easier and quicker to perform and has a lower morbidity compared with open techniques. We present here an overview of the current evidence provided by a literature search performed by Ovid MEDLINE on literature published between January 1993 and May 2003 on endoscopic stapling of pharyngeal pouch. Several case series have been reported on various aspects of the surgery. The modifications in technique, peri-operative care, success rate, complications and recurrence are summarized, based on observational analytical case series. There were no randomized controlled trials comparing this approach to any other endoscopic or open surgical techniques for pharyngeal pouch.

Exostoses of the external auditory meatus is a well known condition which infrequently requires surgical correction. However, the stenosis caused by severe exostosis can affect quality of life considerably and may require surgical intervention. Canalplasty, in such a situation, is a valid and effective management option. In our series the commonest indication for surgery was recurrent otitis externa. The detailed surgical technique is described and a retrospective analysis of 65 such procedures is presented. There were only two significant complications, both post-operative stenosis, requiring further corrective surgery. In conclusion, canalplasty for the exostosis of the external auditory meatus is a safe surgical option.

The primary aim of treatment of cholesteatoma is to attain a dry, safe, stable ear, free of disease. Maintaining or improving hearing is important but the pursuit of a hearing result should not compromise this primary aim. This study reviews the long-term outcome of 133 patients, suffering from advanced disease, who underwent modified radical mastoidectomy between 1995 and 2000. Of these, 49 per cent had had previous mastoid surgery elsewhere. A dry, waterproof ear was attained in 95 per cent of patients. In 77 per cent of patients, hearing was unchanged or improved. In this period, there were two cases of significant post-operative loss in bone conduction, including one dead ear secondary to suppurative labyrinthitis. There were epithelial pearls on follow up in two per cent. These results indicate that when properly performed, modified radical mastoidectomy provides safe surgical access and clears disease with low recurrence rates while mostly maintaining or improving hearing.

Similarities between osteoporosis and otosclerosis have been noted, including a similar association with the COL1A1 gene. Herein, the authors explore the possible clinical relationship between these two common disorders of bone. In this retrospective study, the medical charts of 100 women aged 50 through 75 years who had undergone stapedectomy for otosclerosis were reviewed and the prevalence of osteoporosis in these women was noted. Similarly, the prevalence of osteoporosis was determined in a control group of 100 women aged 50 to 75 years with presbycusis. Fifteen of 100 women with otosclerosis had a concomitant diagnosis of osteoporosis as compared with four of 100 women with presbycusis, yielding a significant clinical association (p = 0.007) between otosclerosis and osteoporosis. This study suggests an association between otosclerosis and osteoporosis, providing impetus and justification for future prospective clinical studies and related research.

During the last 26 years the annual number of diagnosed vestibular schwannomas (VS) has been increasing. The aim of this study is to describe and analyse this increase. Since 1976, 1446 new cases of VS have been diagnosed at the authors’ centre. Special focus was on the age at diagnosis, the localization and the size of the tumour. The size of the tumour was registered as either intrameatal or with the largest extrameatal diameter. The annual number of diagnosed VS has increased from 26 in 1976 to 101 in 2001. The size of the diagnosed tumours has decreased from a median of 35 mm in 1979 to 10 mm in 2001. In the first years large and giant tumours dominated, in contrast to recent years in which intrameatal and small tumours dominated. The median age at the time of diagnosis has been almost unchanged through the period (median 55 years). If the decreasing size of the tumour and the increasing incidence of VS can be explained only by earlier diagnosis and easier access to magnetic resonance (MR) scanning it should be expected that the median age at the time of diagnosis would decrease simultaneously. In this study, the median age at the time of diagnosis has been almost unchanged throughout the 26-year period. This paradox can be explained by the fact that, with easier access to MR scanning, the examination has been offered also to elderly patients, in whom the small and intrameatal tumours dominate.

This study evaluated the long-term results of endoscopic dacrocystorhinostomy (DCR) performed as a day-case procedure under local anaesthesia. It assessed the patient satisfaction with the procedure by retrospective review and a questionnaire survey.

Seventy patients were referred for endoscopic DCR to the senior author between 1997 and 2000. A success rate of 92 per cent was achieved at three months and it was possible to perform 85 per cent of cases under local anaesthetic; 91 per cent were discharged on the same day. Long-term follow up by postal survey revealed that the watering eye had improved following surgery in 83 per cent (follow up range = eight to 66 months; mean = 28.6 months). Eighty-eight per cent were satisfied with the tolerability of the procedure under local anaesthesia.

The authors describe changes in technique, which evolved with their experience of the procedure. Endoscopic dacrocystorhinostomy can be performed safely and successfully as a day-case procedure under local anaesthesia with excellent results and with great satisfaction to the patients.

Recent government initiatives in the UK have focused on streamlining oncology services by reducing waiting times between urgent referral, assessment and treatment of patients with possible cancer. The performance of the Quick Early Diagnosis Dysphonia Clinic of the Queen Elizabeth Hospital, Birmingham, between May 1997 and April 2001 was reviewed. Of 721 patients reviewed, 123 (17 per cent) had clinically suspicious laryngeal lesions. Thirteen cases of epithelial hyperplastic laryngeal lesions and 27 laryngeal malignancies were diagnosed. There was no statistical link between early cancer detection and assessment within two weeks of referral. However, rapid-access clinics for dysphonia serve an important role in the reassurance and multidisciplinary management of patients with persistent hoarseness. Greater financial commitments are necessary to achieve compliance with objectives for a maximum two-week wait for patients with suspected laryngeal malignancy.

This article highlights the indications for frontal sinus obliteration and suggests some intra-operative points to aid the surgeon in performing the operative procedure. It also reiterates the three principal points that need to be followed. There must be:

(1) Meticulous removal of all visible mucosa and the inner bony cortex of the sinus wall.

(2) Permanent occlusion of the nasofrontal duct.

(3) The correct choice of material for the obliteration.

Granuloma annulare is a benign, idiopathic, inflammatory dermatosis characterized clinically by dermal papules and annular plaques. We describe the case of a 40-year-old man who presented with a long history of multiple nodules on the left pinna. Histological examination revealed the typical necrobiotic granulomas of granuloma annulare. The condition predominantly affects the extremities of children and young adults; cases involving the pinna are extremely rare.

Nodular lesions are common in otolaryngological practice, and this case illustrates the need for careful clinical assessment and appropriate biopsy in diagnosing lesions of the outer ear

An eight-year-old boy with Treacher Collins syndrome was fitted with a bone-anchored hearing aid. The audiometric result was excellent. Two years later, the abutment began to loosen and could not be tightened. It was thought that a new fixture would be required, with loss of use of the aid for three months. At surgery, bone was found to be growing over the hexagonal joint between fixture and abutment. A simple and rapid solution to this problem is described.

There has been a steady increase in the number of cases of methicillin-resistant Staphylococcus aureus (MRSA) otorrhoea; this is a growing concern. The purpose of this study was to evaluate the efficacy of topical vancomycin treatment in patients with MRSA otorrhoea. Fifty-five patients with MRSA otorrhoea were prospectively enrolled into the study. Thirty-five patients were treated with vancomycin eardrops as outpatients. The concentration of the locally prepared vancomycin solution was 25 mg/ml. The dose of vancomycin was two drops three times daily for 10 days. As a control group, 20 patients were treated with gentamicin 0.3% solution. Data were analysed by the Mann-Whitney U test to compare the efficacy of vancomycin eardrops and gentamicin eardrops. In the vancomycin group, the otorrhoea was significantly reduced in 33 ears (94%); in the gentamicin group, in four ears (20 per cent); this reduction was statistically significant (P < 0.03). The use of topical vancomycin treatment was effective for patients with MRSA otorrhoea refractory to conventional antibiotic treatment.

The authors report a novel treatment of a case of type I laryngeal cleft diagnosed in an adult. They describe a technique of endoscopic obliteration of the posterior commissure defect. Initially, a test implant of starch and adrenaline was used, followed by permanent staged injections of Bioplastique™ to the posterior commissure. This rare congenital anomaly usually presents in childhood but late presentation should be considered when adults present with lifelong dysphonia especially when associated with gastro-oesophageal reflux disease.

We present a laryngectomized patient with unspecific complaints of fatigue whose laboratory findings were out of proportion with the clinical presentation. The enormously high blood levels of creatine kinase (CPK) (8000 IU/l, normal range 30–190 IU/l) and thyroid-stimulating hormone (100 mU/l, normal range 0.5–4.5 mU/l) led to diagnosis and treatment of and recovery from hypothyroid myopathy. Hypothyroidism reduces the ability of the muscle to maintain its adequate energetic economy, via several suggested mechanisms. This may lead to injury (myopathy) that allows enzymes such as CPK to leak out of cells and causes elevation of their serum levels. To our knowledge, this is the first reported case of a patient previously treated for head and neck cancer who developed hypothyroid myopathy, presenting with exceptionally elevated CPK levels. This is noteworthy, since hypothyroidism may be easily avoided by a comprehensive follow-up of patients treated for head and neck cancer.

Somatostatins are neuropeptides that have a downregulatory effect on various physiological processes. Their use in the management of certain endocrine tumours is well recognized. Their use in thyroid cancer is not established, although there is some evidence to suggest that they have a role in advanced metastatic disease. We report a case of a patient with advanced metastatic follicular thyroid cancer which demonstrated strong octreotide uptake with reduced avidity for I131. Treatment with the somatostatin analogue octreotide, however, failed to achieve a significant response. We feel this case is important as it suggests that although octreotide provides a useful further imaging modality in differentiated thyroid cancer, it has no therapeutic role.

A case of lobular capillary haemangioma of the trachea is presented. The patient gave a history of foreign body sensation in the throat and multiple episodes of haemoptysis. The chest X-ray was normal. A spiral computed tomograph (CT) with three-dimensional reconstruction revealed a small tracheal mass in the antero-lateral wall of the trachea, which was excised by endoscopy. The histopathological diagnosis was lobular capillary haemangioma, a rare, benign tumour of the trachea. A high index of suspicion with the spiral CT finding was responsible for early diagnosis of the tumour.