Gordon Smyth had a deep emotional investment in closed cavity surgery for cholesteatoma but, nonetheless, later acknowledged that he believed that he had been mistaken. Emotional investments create problems for all surgeons. Sometimes they have difficulty in recognizing that they need to change what they are doing. This is especially important in the management of Ménière’s disease where unproven surgical procedures are often perpetuated. Surgery on the endolymphatic sac is of doubtful value but still continues to be the most frequently performed operation for this condition. Surgeons need to reconsider the evidence and question the appropriateness of these operations.

The civil claim of occupational rhinitis may be difficult to prove on the balance of probabilities and is the responsibility of the claimant. There are two types of occupational rhinitis, an allergic rhinitis or a rhinitis due to irritation. Occupational rhinitis can be likened to occupational asthma. Particular attention must be paid to the relationship to alleged exposure and symptoms. Irritation causes symptoms during exposure that cease afterwards unless clinically obvious damage has occurred. Tobacco smoke and nicotine may also cause symptoms. A full examination, both externally and internally of the nose, mouth and eyes should be undertaken. The presence of squamous metaplasia is important. The validity of a claimant’s symptoms must be checked against the medical records. Details of all occupations, compounds and protection should be noted. Manufacturing data on the compounds should also be obtained. The Health and Safety Executive publish occupational exposure limits for many industrial chemicals. Allergen-specific IgE may be raised when an allergy is considered to cause the occupational rhinitis. Nasal challenge tests have been used in Scandinavia to diagnose allergic occupational rhinitis. The sense of smell should be tested. There are two approaches, detecting threshold or recognition, which is suprathreshold. When present, three degrees of social effect occur: impairment, disability and handicap. The degree depends on the occupation of the individual.

Referral rates from individual partners within two demographically matched general practices to the local ENT service were gathered prospectively over a six-year period. The study was designed to determine if extra training in one practice altered these rates. A single partner from one practice attended otolaryngology clinics for regular training over a three-year period. This was funded by the local Family Practitioners’ Committee. The funding enabled a locum to cover this partner’s clinical commitment whilst he attended the specialist clinics for continued ENT training. The aim of this study was to identify whether the provision of continued ENT training and education to general practitioners (GPs) influenced referral patterns to specialist clinics.

Data have been collected prospectively from 11 patients (12 affected ears) with traumatic disruption of the ossicular chain. Isolated dislocation of the incus is the most common finding in our cases, but two had stapes arch features and two had fractures of the tympanic bone. The most common cause of the injuries was a road traffic accident. We describe a technique designed to reposition the incus in its physiological position. This involves a combination of a tympanotomy and a posterior approach to the attic region. The results in five patients (six ears) treated in this way are presented.

Fifty-eight patients underwent vestibular neurotomy via the posterior fossa approach between September 1992 and December 1998 at the ENT department of Legnano. All patients presented a history of disabling unilateral Menière’s disease and underwent complete neuro-otologic evaluation following the 1985 American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) guidelines. All patients underwent MRI imaging, ABR and electronystagmographic testing before surgery. Objective analysis of results is reported using the criteria published by the Committee on Hearing and Equilibrium of the AAO-HNS in 1985. According to the AAO formula, 52 patients obtained a score of 0, indicating complete control of major vertigo spells, while four were classified within the ’substantial control’ group. Immediate hearing results indicated that 93 per cent of the patients maintained a level within 10 dB from the preoperative level. Only one patient experienced a subtotal hearing loss yet retained measurable hearing. No major complications were reported. We conclude that a retrosigmoid approach to vestibular neurotomy can be considered a safe and effective procedure in relieving medically refractory vertigo in Menière’s disease while preserving the hearing. Tinnitus and long-term hearing deterioration are not influenced by the procedure.

This study aims to investigate the facilities available in Accident and Emergency (A&E) departments and the education of casualty officers in the treatment of epistaxis in the UK. Fifty departments were chosen at random and a telephone survey undertaken. The results show a paucity of facilities and inadequate training of A&E officers in a majority of departments. Recommendations for treatment standards are made.

Although transnasal techniques to treat choanal atresia have become the standard, risks remain of restenosis of the opened choana requiring dilatations. In addition, a new technique without stenting and requiring less invasive post-operative care would be an improvement. With this in mind, in a non-randomized trial, a modification of the transnasal surgical repair was used in eight patients with unilateral choanal atresia by which no stents were used. While the standard procedure consists of partial resection of the bony septum and the atretic plate, we additionally removed lower parts of the anterior wall and the floor of the sphenoid sinus, creating a new airway canal from the nasal cavity to the sphenoid into the epipharynx. Post-operative care by the patient and the surgeon was noted. The success of choanal patency was followed by nasal endoscopy and rhinomanometry with a mean post-operative follow-up time of 1.9 years. In all patients, both choanae remained patent confirmed by nasal endoscopy and rhinomanometry showing almost symmetric resistance. Post-operative care comprised antibiotic prophylaxis and nasal douching with saline solution by the patient; no further treatment by the surgeon was necessary. According to these long-term results we would recommend this type of surgery for two reasons: the use of stents no longer necessary and post-operative care by the surgeon can be minimized.

A Th1/Th2 cytokine imbalance with a predominance of Th1 cytokines has been suggested to be of pathogenic importance in Wegener’s granulomatosis. To evaluate the role of Th1/Th2 cytokines in Wegener’s granulomatosis, the subsets of Th1, Th2, Tc1 and Tc2 cells from patients with active Wegener’s granulomatosis were examined by intracellular cytokine flow cytometry. The population of Tc1 cells (72.0 ± 14.4 per cent) in Wegener’s granulomatosis was significantly increased compared with Tc1 cells (37.3 ± 14.6 per cent) in control (p<0.05). Th1, Th2 and Tc2 cells in Wegener’s granulomatosis were not significantly increased compared with the control cells. These results indicate that the predominance of Tc1 cells might contribute to the mechanism of the pathogenesis of Wegener’s granulomatosis.

The Bcl10 gene encodes a protein probably involved in some apoptotic regulatory pathways. Bcl10 mutations lead to the translation of truncated proteins that show gain-of-function transforming activity; it has been suggested thaBcl10 may represent a major target gene for inactivation in many human cancers. To define the frequency of Bcl10 mutations in laryngeal squamous cell carcinoma and their possible association with tumour progression, we investigated a large panel of tumours representative of all grades and stages of malignancy.

To detect pathogenic mutations in exons 1, 2 and 3 of the Bcl10 gene, we performed a silver-staining polymerase chain reaction – single-strand conformation polymorphism (PCR-SSCP) analysis followed by direct DNA sequencing. We revealed the presence of SSCP variants in 18 out of 91 laryngeal tumours. Direct DNA sequencing showed previously described polymorphisms but no pathogenic mutations. We have strong evidence that the Bcl10 gene is not involved in laryngeal carcinogenesis.

Airway invasion is a life-threatening complication of thyroid cancer. An important issue that deserves better attention is the differentiation between the clinical features of tracheal wall invasion versus those of an obstructive endotracheal lesion. We present information on the clinical course, diagnostic modalities utilized, management instituted, along with the prognosis, and follow-up data on a group of patients presenting with obstructive endotracheal lesions of thyroid cancer. Two thousand four hundred and eighty-nine thyroid cancer patients were seen at our institution from December 1975 to May 2000. Thirteen patients presented with symptoms of respiratory distress related to obstructive endotracheal lesions. At presentation, 11 patients underwent endoscopic examination. Imaging studies consisting of I123 whole body scan (WBS), computed tomography/magnetic resonance imaging (CT/MRI) of neck and chest, whole body positron emission tomography using 18-fluoro-2-deoxy-D-glucose (FDGPET) were done, as also was determination of the tumour markers, serum thyroglobulin (TG) and calcitonin. Patients were followed for one to 108 months after the initial presentation. Intraluminal tracheal obstruction was severe in eight patients; five had near-total-occlusion. Paralysis of the vocal folds was present in five. Evidence of metastatic disease was present in most patients. Dissociation between iodine uptake and TG synthesis was evident in five patients during follow-up. Four patients died of cancer. Of the nine living patients; cancer persisted in six, recurred in two patients, and remitted in one. This study has identified obstructive endotracheal lesion of thyroid cancer as a distinct entity apart from tracheal wall disease. These data provide evidence that intraluminal tracheal invasion of thyroid cancer is an ominous sign and a frequent cause of morbidity.

The objective of this study was to assess patency of the internal jugular vein following modified radical or selective neck dissection and microvascular flap reconstruction by power Doppler ultrasound and its impact on free flap survival. In 23 patients who underwent selective or modified radical neck dissection and microvascular flap reconstruction the patency of the internal jugular vein was examined by power Doppler ultrasound on the first post-operative day and after follow-up of at least four months. On the first post-operative day in one patient partial thrombosis was found, while in the other 22 patients the internal jugular vein was normal patent. During follow-up in 17 (74 per cent) patients a normal patent internal jugular vein was found, while partial and complete thrombosis were found in three (13 per cent) patients each. On the first post-operative day 22 of the 23 (96 per cent) free flap veins were visualized. There was no free flap loss during follow-up. Power Doppler ultrasound is a valuable diagnostic technique for determination of internal jugular vein patency and may be useful as screening method or in case of clinical suspicion of thrombosis to determine internal jugular vein patency. Late internal jugular vein thrombosis may probably not effect free flap survival due to neovascularization.

Tracheocutaneous fistula is a frequent sequel of long-term tracheostomy or tracheal fenestration. Closure of fistula is complicated by the presence of extensive scar tissue, mucopurulent secretions, and tension from insufficient advancement of adjacent soft tissue. We report two successfully closed cases of large tracheocutaneous fistulae using a hinge flap and a V-Y advancement flap.

We present two subjects with previously undiagnosed acoustic neuromas who complained of vertigo whenever they ran. One had normal hearing while the other already had a unilateral sensorineural deafness. Hyperventilation for 30 seconds provoked an ipsilateral beating nystagmus and reproduced the vertiginous sensation in both subjects. Hyperventilation is a simple bedside test that should be performed when assessing a subject with vertigo or when there is a clinical suspicion of an acoustic neuroma.

This is a case of a 35-year-old who had complained of noisy breathing for 15 years, and had been on treatment for ‘chronic asthma’. She presented to the Accident and Emergency department with an acute episode of difficulty with breathing, and on admission was found to have stridor and bilateral abductor vocal fold palsy. Further workup revealed a syringomyelia with an associated Chiari type 1 malformation. It is important to consider the above diagnosis in the differential of young adults with breathing difficulties. A discussion of syringomyelia, Chiai malformations and bilateral vocal fold palsy follows.

Neurofibroma of the soft palate, an extremely rare tumour, is probably not yet reported in the literature. We report the first case of an isolated neurofibroma of the soft palate not associated with von Recklinghausen’s disease (VRD), which is also, probably, the first reported case of neurofibroma of the soft palate. The tumour was completely removed from the soft palate after performing tracheostomy, necessitated due to difficulties in intubation.

Cervical necrotizing fasciitis (CNF) with thoracic extension is rare. It has never been reported in laryngectomized patients. A case of fatal CNF in a laryngectomized patient equipped with a voice prosthesis is presented. Diagnosis and treatment are discussed. CNF with thoracic extension was diagnosed on clinical picture, computed tomography (CT) and biopsies were taken just above the tracheostoma. Antibiotic treatment was started and extensive debridement of the affected tissues performed. A minor extension to the left pleura was considered irresectable. Irradical debridement and the impossibility of administering hyperbaric oxygen therapy caused death within two day after presentation. CNF is a rare disease and to our knowledge, has never been reported after total laryngectomy. This case emphasizes the need for early antibiotic treatment and radical surgical resection of the affected tissues.

A 32-year-old male presented with a mass in the parotid gland. Superficial parotidectomy was performed. Histopathologically the tumour was found to be schwannoma (neurilemmoma) and because this is unusual, the case is presented together with the histopathological findings.

Mesenchymal chondrosarcoma is a rare, aggressive, malignant neoplasm, which arises from extraskeletal sites in 30–40 per cent of cases. It is extremely rare in children. We present a novel case of childhood mesenchymal chondsarcoma arising from the vagus nerve in the neck, resulting in paralysis of the right vocal fold. The clinicopathologic features and management of this case are described along with a brief discussion on the aetiology of vocal fold paralysis in this age group. Current literature on extraskeletal presentation of mesenchymal chondrosarcoma is reviewed.

Sporadic medullary thyroid carcinoma (MTC) usually presents with a thyroid mass, cervical lymphadenopathy or other local cervical symptoms. Often the diagnosis is unsuspected pre-operatively. We report a unique case of a mixed follicular medullary thyroid carcinoma presenting as a tumour with extreme vascularity. The management of hypervascular thyroid tumours is discussed together with current controversies regarding persistent hypercalcitoninaemia.