Inverted papilloma is the most common benign tumour affecting the nose. There is a high rate of recurrence and a potential of malignant transformation. This review article aimed to identify the best available management of this pathology today.

A systematic review of the current English-language literature was performed. Only original articles with a minimum follow up of one year and an average follow up of two years were included.

A total of 1385 patients from 16 case series were identified. The total recurrence rate for all patients was 11.5 per cent. Significantly lower recurrence rates were found for procedures using an attachment-oriented excision (recurrence of 6.9 per cent; p = 0.0001) and utilising frozen sections (recurrence of 7.0 per cent; p = 0.0001).

There is a general trend towards endoscopic surgery. There may be some benefit to the use of attachment-oriented surgery and frozen sections. Multi-centred randomised controlled trials are required.

Endoscopic sphenopalatine artery ligation is widely accepted as effective and safe for acute spontaneous epistaxis that is unresponsive to conservative management. As with many new procedures, it has been progressively adopted as common practice, despite a limited evidence base for its efficacy. Early reviews called for comparative trials to support its adoption, but subsequent literature largely consists of case series and narrative reviews. These have attempted to derive an algorithm to establish its place in management, but consensus is still lacking. Intuitively, although there are theoretical objections, an operation regarded as relatively simple, fast and safe hardly seems to demand high-level evidence of efficacy. Rhinologists may be influenced by years of personal experience and success with the technique. However, estimates of the effect size and the added contribution to traditional surgical management are lacking. If the procedure could be shown to dramatically influence outcome, it should be standard practice and indispensable for all patients requiring operative intervention.

This paper systematically examined the literature, appraising the anatomical basis for such an approach and evidence for its efficacy. It questions whether any units unable to consistently offer endoscopic sphenopalatine artery ligation should be undertaking surgical management of acute epistaxis.

Histopathological anomalies of inner-ear structures in individuals with Down syndrome have been well documented; however, few studies have examined the radiological features.

A retrospective study was conducted of temporal bone computed tomography images in 38 individuals (75 ears) with Down syndrome to evaluate the prevalence of inner-ear abnormalities and assess vestibular aqueduct widths.

Inner-ear anomalies were identified in 20 of the 38 individuals (52.6 per cent). Seven of the 75 temporal bones (9.3 per cent) were found to have higher than previously reported. A dilated internal auditory canal and vestibule were more common among the present study group, while prior studies have demonstrated internal auditory canal stenosis and decreased vestibule size.

Down syndrome patients exhibit a high prevalence of dysplastic inner-ear features that confer substantial risk of sensorineural hearing loss. Computed tomography is a useful screening aid to detect inner-ear abnormalities, particularly enlarged vestibular aqueducts, which cause preventable sensorineural hearing loss in this population.

Osteoradionecrosis is a significant complication of head and neck cancer treatment, and its most severe form (grade III) necessitates radical surgery. This study aimed to compare the cost of free-flap reconstructive surgery for grade III osteoradionecrosis and similar non-osteoradionecrosis cases in order to assess the cost burden of osteoradionecrosis treatment.

All patients who underwent free-flap reconstructive surgery for osteoradionecrosis between July 2004 and July 2010 at Auckland City Hospital (19 patients) were identified, and relevant data were collected retrospectively. These patients were matched in terms of age and sex with patients who underwent free-flap reconstructive surgery.

The treatment cost was 44 per cent higher in osteoradionecrosis patients when compared to non-osteoradionecrosis patients.

The significant financial burden on the health system, and the growing evidence for the effectiveness of pentoxifylline, tocopherol and clodronate, should prompt us to explore this alternative treatment further.

To determine the pre- and post-operative prevalence of dizziness, tinnitus and taste disturbances in adult cochlear implant recipients.

A questionnaire regarding pre- and post-operative dizziness, tinnitus and taste disturbances was sent to 170 cochlear implant recipients implanted between January 2003 and March 2009. Seventy-seven patients (41 per cent) responded.

Pre-operatively, 20 per cent of the participants experienced dizziness, 52 per cent experienced tinnitus and 3 per cent experienced taste disturbances. Post-operative dizziness developed in 46 per cent of patients and resolved in the majority of these; however, 15 per cent reported dizziness more than six months after implantation. Tinnitus worsened in 25 per cent of patients, whereas 73 per cent reported attenuation or termination of tinnitus. Post-operatively, tinnitus developed in 12 per cent and taste disturbances developed in 17 per cent of the patients.

The high prevalence of dizziness, tinnitus and taste disturbances reported by cochlear implant recipients necessitates that assessment of symptoms related to inner ear and chorda tympani damage are included when evaluating operative results.

Does revision myringoplasty have worse outcomes than primary surgery?

The International Otology Database has been used to record data on surgery for middle-ear disease in Norfolk, UK, over nine years. The data show the results of all myringoplasty cases and the results of revision cases. Outcome measures are perforation and hearing change. Comparison is made with benchmark centres of excellence.

A total of 611 operations included myringoplasty; 356 (58 per cent) of cases had a recorded follow up at 3 months. Twenty-nine patients (8.1 per cent) had a post-operative perforation. Benchmark centres performed 2319 operations; 1284 (55 per cent) of these had a follow up at 3 months, and 82 patients (6.4 per cent) had a perforation at follow up. Sixty-nine of the Norfolk patients were revision cases. Six of the 69 patients (8.7 per cent) had a perforation at follow up. The average hearing gain in the revision myringoplasty patients in Norfolk was 7 dB.

The results of the revision myringoplasty cases are the same as those for the primary myringoplasty cases in this series.

Cholesteatoma patients have a high risk of recurrence with complications, and knowledge exchange is a prerequisite for improving treatment. This study aimed to apply appropriate statistics to provide meaningful and transferable results from cholesteatoma surgery, to highlight independent prognostic factors, and to assess the incidence rate.

Incidence rates were assessed for the district of Aarhus, Denmark. From 147 patients operated on mainly with canal wall up mastoidectomies for debuting cholesteatomas, 10-year Kaplan–Meier recidivism rates were calculated and independent prognostic factors for the recidivism were identified by Cox multivariate regression analyses.

Incidence rate was 6.8 per 100 000 per year. The 10-year cumulative recidivism rate was 0.44 (95 per cent confidence interval, 0.37–0.53). Independent prognostic factors for the recidivism were: age below 15 years (hazard ratio = 2.2; p > z = 0.002), cholesteatoma localised to the mastoid (hazard ratio = 1.7; p > z = 0.04), stapes erosion (hazard ratio = 1.9; p > z = 0.02) and incus erosion (hazard ratio = 1.9; p > z = 0.04).

The recidivism rate is influenced by several factors that are important to observe, both in the clinic and when comparing results from surgery.

A distinct nerve innervating the external auditory canal can often be identified in close relation to the facial nerve when gradually thinning the posterior canal wall. This nerve has been attributed to coughing during cerumen removal, neuralgic pain, Hitselberger's sign and vesicular eruptions described in Ramsay Hunt's syndrome. This study aimed to demonstrate the origin and clinical impact of this nerve.

In patients with intractable otalgia or severe coughing whilst inserting a hearing aid, who responded temporarily to local anaesthesia, the symptoms could be resolved by sectioning a sensory branch to the posterior canal. In a temporal bone specimen, it was revealed that this nerve is predominantly a continuation of Arnold's nerve, also receiving fibres from the glossopharyngeal nerve and facial nerve. Histologically, the communicating branch from the facial nerve was confirmed.

Surgeons should be aware of the posterior auricular sensory branch and its clinical implications.

This study aimed to evaluate the presence of the N3 potential (acoustically evoked short latency negative response) in profound sensorineural hearing loss, its association with the cervical vestibular evoked myogenic potential and the relationship between both potentials and loss of auditory function.

Otological examinations of 66 ears from 50 patients aged from 4 to 36 years were performed, and the vestibular evoked myogenic potential and auditory brainstem response were measured.

The N3 potential was recorded in 36 out of 66 ears (55 per cent) and a vestibular evoked myogenic potential was recorded in 34 (52 per cent). The N3 potential was recorded in 23 out of 34 ears (68 per cent) with a vestibular evoked myogenic potential response and absent in 19 out of 32 ears (59 per cent) without a vestibular evoked myogenic potential response. The presence of an N3 potential was significantly associated with a vestibular evoked myogenic potential response (p = 0.028), but there was no significant difference in the latency or amplitude of the N3 potential in either the presence or absence of a vestibular evoked myogenic potential.

The presence of an N3 potential in profound sensorineural hearing loss with good or poor vestibular function can be explained by the contribution of the efferent cochlear pathway through olivocochlear fibres that join the inferior vestibular nerve. This theory is supported by its early latency and reversed polarity, which is masked in normal hearing by auditory brainstem response waves.

This study aimed to develop a multidisciplinary coded dataset standard for nasal surgery and to assess its impact on data accuracy.

An audit of 528 patients undergoing septal and/or inferior turbinate surgery, rhinoplasty and/or septorhinoplasty, and nasal fracture surgery was undertaken.

A total of 200 septoplasties, 109 septorhinoplasties, 57 complex septorhinoplasties and 116 nasal fractures were analysed. There were 76 (14.4 per cent) changes to the primary diagnosis. Septorhinoplasties were the most commonly amended procedures. The overall audit-related income change for nasal surgery was £8.78 per patient. Use of a multidisciplinary coded dataset standard revealed that nasal diagnoses were under-coded; a significant proportion of patients received more precise diagnoses following the audit. There was also significant under-coding of both morbidities and revision surgery.

The multidisciplinary coded dataset standard approach can improve the accuracy of both data capture and information flow, and, thus, ultimately create a more reliable dataset for use outcomes and health planning.

When performing septoplasty or septorhinoplasty, we have observed that patients blink on injection of local anaesthetic (lidocaine 1 per cent with adrenaline 1:80 000) into the nasal mucosa of the anterior septum or vestibular skin, despite appropriate general anaesthesia. This study sought to quantify this phenomenon by conducting a prospective audit of all patients undergoing septoplasty or septorhinoplasty.

Patients were observed for a blink reflex at the time of local anaesthetic infiltration into the nasal vestibule. Also measured at this point were propofol target-controlled infusion levels, remifentanil rate, bispectral index, blood pressure, heart rate, pupil size and position, and patient movement.

There were 15 blink reflexes in the 30 patients observed. The average bispectral index value was 32.75 (range, 22–50) in the blink group and 26.77 (range, 18–49) in the non-blink group. No patients moved on local anaesthetic injection.

The blink reflex appears to occur in 50 per cent of patients, despite a deep level of anaesthesia. Without an understanding and appreciation of the blink reflex, this event may result in a request to deepen anaesthesia, but this is not necessary and surgery can proceed safely.

To validate the ovine model of profound oropharyngeal dysphagia and compare swallowing outcomes of laryngotracheal separation with those of total laryngectomy.

Under real-time fluoroscopy, swallowing trials were conducted using the head and neck of two Dorper cross ewes and one human cadaver, secured in lateral fluoroscopic orientation. Barium trials were administered at baseline, pre- and post-laryngohyoid suspension, following laryngotracheal separation, and following laryngectomy in the ovine model.

Mean pre-intervention Penetration Aspiration Scale and National Institutes of Health Swallow Safety Scale scores were 8 ± 0 and 6 ± 0 respectively in sheep and human cadavers, with 100 per cent intra- and inter-species reproducibility. These scores improved to 1 ± 0 and 2 ± 0 post-laryngohyoid suspension (p < 0.01). Aerodigestive tract residue was 18.6 ± 2.4 ml at baseline, 15.4 ± 3.8 ml after laryngotracheal separation and 3.0 ± 0.7 ml after total laryngectomy (p < 0.001).

The ovine model displayed perfect intra- and inter- species reliability for the Penetration Aspiration Scale and Swallow Safety Scale. Less aerodigestive tract residue after narrow-field laryngectomy suggests that swallowing outcomes after total laryngectomy are superior to those after laryngotracheal separation.

Parkinson's disease is a degenerative disorder of the central nervous system, mainly affecting motor functions including the voice. The aetiology of dysphonia changes throughout the course of disease progression.

This study aimed to determine the laryngeal changes seen in early-, mid- and late-stage Parkinson's disease. Thirteen patients with Parkinson's disease are presented, representing the largest series of voice patients with Parkinson's disease seen in a voice clinic in the literature.

Age, gender, severity of handicap caused by voice disorder and possible associated reflux symptoms were examined.

Laryngeal function appeared to change gradually with progression of the disease, and may have been affected by the presence of pre-existing laryngeal pathology.

Laryngeal function in Parkinson's disease appears to go through a series of changes that may be helped by both therapeutic and surgical interventions. These patients should be treated within the confines of a voice clinic multidisciplinary model.

This study aimed to develop a simple and accurate method to diagnose paediatric obstructive sleep apnoea hypopnea syndrome.

A total of 311 children with suspected paediatric obstructive sleep apnoea hypopnea syndrome were included in the study. Multiple clinical parameters, including sex, age, body mass index, history of snoring or gasping, history of nasal obstruction, history of running nose, palatine tonsil size, adenoid to nasopharynx ratio, and tympanogram type, were compared with polysomnography results using relevant correlation and regression analyses. A diagnostic scale was established using the regression equation and the correlation between the polysomnography result and scale result was determined.

The apnoea–hypopnea index correlated significantly with a history of snoring or gasping, palatine tonsil size, and tympanogram type. Stepwise logistic regression analysis revealed that the polysomnography result correlated significantly with a history of snoring or gasping, palatine tonsil size, and the adenoid to nasopharynx ratio. The percentage correlation between the scale and polysomnography results was 77.8 per cent.

The diagnostic scale can be used to diagnose paediatric obstructive sleep apnoea hypopnea syndrome for clinical application when polysomnography cannot be performed. However, it is not suitable for assessing the severity of paediatric obstructive sleep apnoea hypopnea syndrome.

Occult differentiated thyroid carcinomas are not uncommon. The initial presentation of a thyroid carcinoma is often detection of a metastatic cervical lymph node.

A retrospective review was performed of the medical records of 304 patients who underwent neck dissection between 1996 and 2008 for squamous cell carcinoma of the head and neck.

Ten patients (3.3 per cent) had nodal metastasis originating from papillary thyroid cancer. All of these patients underwent thyroidectomy and post-operative 131iodine radiometabolic therapy. No patient developed a thyroid tumour after surgery.

Despite its metastatic spread, thyroid cancer does not affect the overall prognosis of patients who are already being treated for a more aggressive malignancy. However, in otherwise healthy patients, it is worth treating this second malignancy to avoid potential complications related to local disease or metastatic thyroid cancer.