Neurogenic tumours form a very small percentage of all neoplastic lesions of the head and neck region. However, the head and neck region is by far the most common location for benign peripheral nerve tumours. Several cases involving the nose have been sporadically documented throughout the medical literature.

We present a rare case of a solitary neurofibroma arising from the lateral nasal wall of a 68-year-old woman. En bloc surgical resection of the mass was achieved by the lateral rhinotomy approach.

The clinical significance of this case report is due to its rare site. In recent medical literature, there has been only one report concerning a solitary neurofibroma arising from the inferior turbinate. This case also highlights the importance of considering this clinical entity in the differential diagnosis when encountering a unilateral soft tissue mass in the nasal cavity.

Syringocystadenoma papilliferum is a benign adnexal skin tumour, which, in a third of cases, arises from an organoid nevus on the head and neck. We report on a 17-year-old man with a syringocystadenoma papilliferum on his right pinna of three-years duration. The clinical and histopathological features are described. Following excision and skin grafting, the patient remains asymptomatic four years after surgery. This is the first report of a syringocystadenoma papilliferum on the pinna.

Within the last 10 to 15 years, a significant amount of research in tonsil surgery has focused on reduction of post-operative pain and recovery time. In order to minimize or avoid morbidity, a number of otolaryngologists in the United States and Europe have revived a historical procedure, previously known as ‘tonsillotomy’, specifically for those patients with obstructive sleep-disordered breathing (OSDB) due to adenotonsillar hypertrophy. More recently, surgeons have used terms such as partial tonsillectomy, partial intracapsular tonsillectomy or subtotal tonsillectomy to describe their procedure and have employed a variety of modern instrumentation. This return to a ‘partial’ procedure has generated a debate similar to that which occurred amongst tonsil surgeons about 100 years ago, when tonsillotomy was the most commonly performed procedure. Today, concerns about regrowth and problems with infection of the remaining tonsillar tissue have been raised. Such concerns, combined with an incomplete understanding of why the ‘partial’ procedure was abandoned in the early twentieth century, may explain why tonsil surgeons hesitate to change their approach to patients with OSDB due to adenotonsillar hypertrophy. These issues can be addressed in a meaningful way only through a detailed review of the evolution of tonsil surgery, which is presented here. This information, along with a summary of the last 10 years' experience with these techniques, supports the use of a ‘partial’ procedure in children with OSDB due to adenotonsillar hypertrophy. Future areas of research are also discussed.

Background: Seeking to identify where litigious claims against otolaryngologists are targeted (i.e. areas of highest risk) within the NHS and private sector would have positive implications in risk management and limiting the amount of litigation against otolaryngologists.

Method: The National Health Service Litigation Authority (NHSLA) and Medical Defence Union (MDU) were contacted and anonymous data obtained on claims within ENT.

Results: 887 claims were notified – 457 NHSLA and 430 MDU. The commonest claim in both groups was failure or delay in diagnosis (12 per cent NHSLA, 23 per cent MDU). The other commonest claims were all related to complications (nerve damage 10 per cent, deafness 8 per cent and dental damage 5 per cent). Dissatisfaction with results was 8 per cent total and, within the private sector, was almost exclusively in rhinology.

Conclusions: This study once again emphasizes the need for thorough clinical assessment, record keeping and good communication with patients. Recognising these areas of highest risk may limit future claims.

We investigated the motion of the single ossicle found in the middle ears of four different species of birds. In the avian middle ear, the off centre attachment of the extracolumella to the tympanic membrane and the flexion of the joint between the extracolumella and columella results in rocking of the footplate rather than direct excursion in and out of the vestibule. We postulate that this is a protective mechanism to avoid excessive displacement of the footplate into the vestibule during changes in middle-ear pressure and that it is analogous to the ossicular ‘decoupling’ observed in the human middle ear in the same circumstances.

Cochlear implantation is a high cost, low volume intervention which is provided to adults and children with profound hearing impairment. Demand is increasing in the UK as a result of improved technology, changes in intervention criteria and the national newborn hearing screening programme. In order to inform commissioning policy for cochlear implantation in five English primary care trusts, we reviewed the evidence and assessed the complexities of developing needs and of service provision assessment and planning. Our results indicated that the current level of provision was well below what would be expected if the majority of people meeting current criteria were given a cochlear implant. Gaps between the clinical intervention thresholds and the level of service commissioned have widened. Long-term cost effectiveness and incidence studies are needed to assess cochlear implantation in the light of these lower clinical intervention thresholds.

Introduction: Radical mastoidectomy and tympanomastoid obliteration with fat tissue, also called the Rambo operation, is proposed to those patients suffering chronic middle-ear disease, with or without cholesteatoma, who have no useful hearing in an ear which cannot be kept dry despite all conservative treatment.

Methods: We analysed retrospectively a series of 46 patients operated upon in our department. Information recorded included the surgical indications, surgical observations, post-operative care and complications. All patients were invited to comment on their long term anatomical and functional results and to express their degree of satisfaction with the procedure.

Results: Recurrent infectious episodes were observed in seven cases. Residual cholesteatoma were observed in three cases. After treatment, these patients did not present with further complications. One case presented with multiple episodes of infection with recurrences of cholesteatoma and finally had the obliterated cavity transformed into an open cavity again. For most of the patients, in the long term (i.e. one to 23 years post-operatively (mean eight years)), the operation resulted in a dry ear, ending the need for frequent consultations to clean and disinfect diseased ears or open cavities.

Conclusion: Obliteration of the tympanomastoid cavity, as proposed by Tom Rambo, shortens considerably the post-operative care period, in comparison with canal wall down mastoidectomy, and is therefore indicated if no serviceable hearing can be expected. In the long term, the rate of complications is low and patients are satisfied.

Background: Approximately 20 per cent of adult patients presenting to otolaryngology clinics have symptoms pertaining to the inner ear. These are investigated with magnetic resonance imaging (MRI) internal auditory meatus scans. This study analysed all findings from 736 sequential MRI internal auditory meatus scans performed on 731 patients over a one year period.

Methods: Six hundred and seventy-two patients were included for analysis. Of these, 419 (62.35 per cent) had normal MRI scans, 221 (32.90 per cent) had MRI findings thought to be unrelated to their presenting symptoms, 32 (4.76 per cent) had findings thought to be the cause of their symptoms, and eight (1.19 per cent) had the typical appearance of an VIIIth nerve schwannoma.

Conclusions: Magnetic resonance image scanning of the inner ears and auditory pathways yields a diagnosis of VIIIth nerve tumours of the order of 1 per cent, does not show other causes of inner-ear symptoms in a further 4 per cent, and shows incidental intra- and extracranial abnormalities in a further 33 per cent, most of which are not clinically significant.

Nasal polyps and chronic rhinosinusitis are the products of an inflammatory process. Recently, fungal involvement has been thought to stimulate the development of polyps, and administration of antifungal agents was therefore considered a potential treatment. Several studies have been published indicating amphotericin B as an effective treatment for nasal polyps and chronic rhinosinusitis. The aim of our investigation was to evaluate the efficacy of intranasal applied amphotericin B on the growth of nasal polyps in a three-month, prospective, open trial. Our results show that nasal amphotericin B spray is not effective for nasal polyps and may even cause deterioration.

Introduction: This paper presents our experience with a navigation system for functional endoscopic sinus surgery. In this study, we took particular note of the surgical indications and risks and the measurement precision and preparation time required, and we present one brief case report as an example.

Materials and methods: Between 2000 and 2004, we performed functional endoscopic sinus surgery on 368 patients at the Ludwig Maximilians University, Munich, Germany. We used the Vector Vision Compact® system (BrainLAB) with laser registration. The indications for surgery ranged from severe nasal polyps and chronic sinusitis to malignant tumours of the paranasal sinuses and skull base.

Results: The time needed for data preparation was less than five minutes. The time required for preparation and patient registration depended on the method used and the experience of the user. In the later cases, it took 11 minutes on average, using Z-Touch® registration. The clinical plausibility test produced an average deviation of 1.3 mm. The complications of system use comprised one intra-operative re-registration (18 per cent) and one complete failure (5 per cent). Despite the assistance of an accurate working computer, the anterior ethmoidal artery was incised in one case. However, in all 368 cases, we experienced no cerebrospinal fluid leaks, optic nerve lesions, retrobulbar haematomas or intracerebral bleeding. There were no deaths.

Discussion: From our experience with computer-guided surgical procedures, we conclude that computer-guided navigational systems are so accurate that the risk of misleading the surgeon is minimal. In the future, their use in certain specialized procedures will be not only sensible but mandatory. We recommend their use not only in difficult surgical situations but also in routine procedures and for surgical training.

Subglottic haemangioma is a potentially life-threatening condition for which various treatment modalities are available. The objective of this study was to evaluate our results for open excision of subglottic haemangioma. The study assessed 18 patients who had been treated at a paediatric tertiary referral centre. Most of these patients (83.3 per cent) had undergone open surgical excision without post-operative tracheostomy and had been intubated for several days post-operatively (single-stage procedure). In most of these patients (66.7 per cent), an anterior cartilage graft had been used for reconstruction. The average follow up in this study was 25 months. All the patients in this series had achieved an adequate airway after the procedure. One patient had developed a recurrence of haemangioma in the trachea at a later date. The results of open surgical excision in this study were very encouraging. Seventeen out of 18 (94.4 per cent) patients had avoided tracheostomy or had been decannulated as a direct result of surgery. One of these 18 patients (5.6 per cent) had required a temporary post-operative tracheostomy for 13 months as the subglottis cleared; this was classed as a partial success. Our experience is that open excision is a highly successful ‘one stop’ treatment for subglottic haemangioma, which avoids prolonged use of steroids and multiple endoscopic procedures. No patient in this series developed subglottic stenosis, which can be a significant complication of laser application.

Introduction: Goitre presenting with acute, life-threatening airway compromise is an uncommon indication for thyroid surgery. The management of this critical condition is controversial.

Aims: To investigate the incidence of life-threatening airway compromise in patients with benign goitre, to investigate the predisposing factors, and to outline an optimal management policy for such critical cases.

Methods: Retrospective review of the medical records of patients presenting with life-threatening, acute airway compromise secondary to benign thyroid disease, treated by the senior author (CT) between July 1994 and July 2005.

Results: Of a total of 505 thyroid surgery procedures over the 11-year period, five patients with benign thyroid disease had presented with life-threatening, acute airway compromise. Three of the five patients had been thyrotoxic and two of these had received an iodine load prior to airway compromise. Immediate endotracheal intubation for airway control followed by admission to the intensive care unit had been the presentation in two patients. An incidental diagnosis of tracheal compression had been made from the computed tomography (CT) scan in two patients who had non-resolved obstructive airway disease. Emergency thyroidectomy had been performed in all five patients. Significant tracheomalacia had been noted in four patients. Following thyroidectomy, two patients had required tracheostomy and one had required tracheal stenting.

Conclusion: Chronic obstructive airways disease, substernal extension and long-standing goitre are considered as risk factors for developing acute, life-threatening airway compromise in the presence of benign thyroid disease. A recent iodine load may lead to airway compromise in thyrotoxic patients. A CT scan is indicated in cases of unresponsive chronic obstructive airways disease to rule out substernal extension of non-palpable goitres. Life-threatening airway compromise secondary to benign goitres is best treated by endotracheal intubation if conservative measures fail, followed by emergency thyroidectomy. Following surgery, close observation is mandatory to exclude airway compromise due to tracheomalacia and laryngeal oedema.

The purpose of this study was to assess the significance of the expression of p21WAF1/Cip1 and proliferating cell nuclear antigen (PCNA) in human laryngeal squamous cell carcinomas. Forty-eight patients (25 supraglottic, 23 glottic) who had undergone operations between 1998 and 2003 were included in this study. The Envision immunohistochemistry method was utilized to stain these tissue specimens. The results showed that the immunostaining of p21WAF1/Cip1 do not show any correlation with differentiation, N stage, metastasis, survival, recurrence or the laryngeal site of involvement. A significant inverse correlation was detected between p21WAF1/Cip1 and the T stage. In contrast, the percentage of PCNA labelled cells showed a significant correlation with the T stage, but not with other clinicopathological parameters. There were differences in the expression of p21WAF1/Cip1 and PCNA between the supraglottic and the glottic carcinomas. In conclusion, our findings suggest that p21WAF1/Cip1 and PCNA may play an important role in the progression of carcinoma of the supraglottic larynx.

In general, patients with malignant tumours of the skull base have a poor prognosis. Treatment may have a disfiguring physical and disabling mental effect on patients.

To evaluate the effect of treatment on physical and mental quality of life in patients with skull base malignancy, we conducted a cross-sectional patient survey of 18 patients treated for such tumours, using the University of Washington (version 4) quality of life questionnaire and the hospital anxiety and depression scale.

The total quality of life score (median value) was 980 (550–1125). Patients with anterior skull base malignancy scored lower than those with lateral skull base malignancy (p=0.003).

In general, the worst individual domain scores were: mood (64 per cent); activity (69 per cent); and, specifically for patients with anterior skull base malignancy, taste (54 per cent, p=0.004) and anxiety (60 per cent, p=0.034).

One-third of skull base cancer patients were at risk of suffering from mental distress and psychiatric morbidity (indicated as a score of more than seven on the hospital anxiety and depression scale).

Introduction: Transoral laser microsurgery of locally advanced carcinomas of the lateral oropharynx often results in exposure of major vessels of the neck and may be accompanied by a substantial risk of intra- and post-operative bleeding.

Procedure: Six patients with tonsillar cancers radiologically infiltrating the parapharyngeal space underwent ipsilateral neck dissection with temporary protection of neck vessels. While the neck remained open, transoral laser resection of the primary tumour was performed. Pharyngeal defects were subsequently closed by a superiorly based platysma myofascial flap.

Results: All tumours were completely resected. Intra- and post-operative bleeding complications requiring blood transfusion or surgical revision did not occur. None of the patients developed a cervical fistula. During a mean follow-up time of 24.8 months, no local and/or regional recurrence was observed.

Conclusion: The described approach is oncologically safe and seems to ensure reliable protection of neck vessels during and after transoral laser resection of locally advanced oropharyngeal carcinomas, as well as to prevent fistula formation.

Tracheostomy or laryngectomy stomas may sometimes re-stenose, resulting in respiratory distress for the patient unless the stoma is rapidly re-dilated and an adequate airway re-established.

This article describes a simple and effective method for the acute re-dilatation of a tracheostoma stenosis, using an aural speculum, prior to the insertion of a patent airway tube. This technique has been successfully used in our department since 1995 and, in our experience, causes significantly less distress to our patients when compared with other means employed previously.

A patient presented with unilateral, right-sided hearing loss and tinnitus and underwent gadolinium-enhanced magnetic resonance imaging (MRI). A pure tone audiogram showed a right-sided sensorineural hearing loss. The MRI scan was initially negative but when repeated seven years later, following a further deterioration of symptoms, it showed a 2 mm, right-sided acoustic neuroma.

This case has great potential significance for the diagnosis of acoustic neuroma, and it may raise medico-legal issues regarding the exclusion of this diagnosis. The case illustrates that a single negative scan may not be adequate if pure tone audiograms show deterioration in hearing loss.

Patients with autoimmune inner-ear disease (AIED) are treated with high doses of steroids in the short term when suffering an acute hearing loss. As a consequence, substances such as methotrexate have been employed in the role of steroid-sparing agents. Additionally, it is known that tumour necrosis factor α (TNFα) is an important mediator of the inflammatory process, inhibition of which may be of benefit in AIED. This case report illustrates the use of a TNFα inhibitor in combination with methotrexate, which is known to be an effective combination in rheumatoid arthritis but has yet to be described for sensorineural hearing loss. We conclude that progressive AIED may respond well to TNFα inhibition, whilst more difficult cases, such as this example, could benefit from combining such therapy with methotrexate.

We describe two patients with stapes fixation, in both of whom Rosen mobilization seemed to be the most prudent surgical choice. In both cases, a useful hearing gain was achieved initially. In the patient with otosclerosis, the conductive hearing loss recurred and a stapedectomy was subsequently carried out. In the patient with congenital stapes fixation, the hearing gain was maintained for two years eight months. We believe that this technique still has a place in stapes surgery in rare instances.