In 1914, Adam Politzer (1835–1920) was invited to the Viennese Toynbee Hall to give a lecture. To prepare for his lecture, Politzer wrote a manuscript of 22 pages, seven of them are particularly interesting concerning biographical information on Joseph and Arnold Toynbee. These seven pages are presented in translation from German to English. Politzer particularly emphasizes the social qualities of these two men. This manuscript is representative of his high regard for Joseph and Arnold Toynbee. It completes the few existing biographies of Joseph Toynbee.

Endochondral pseudocyst of the auricle is an uncommon condition that affects predominantly Chinese males, with many reports studying this condition in homogenous Chinese populations. There have been few large-scale reports describing the features of this disease among the other Asian groups. In one of the largest series described to date, we report the epidemiological features, clinico-pathologic characteristics, and success of surgical treatment in 40 patients of different Asian groups presenting with pseudocyst of the auricle. Results showed a Chinese predominance (90 per cent), followed by Malays (five per cent) and Eurasians (five per cent). All had unilateral presentations apart from one patient. Most (55 per cent) presented within two weeks of auricular swelling. Few (10 per cent) had a history of trauma. The pseudocysts predominantly affected the concha (61 per cent). Surgery comprised excision of the anterior wall followed by local pressure application. Only 2.5 per cent had recurrence after surgery. These findings confirm earlier understood features of this disease while revealing some notable variations.

The need to reduce costs while providing a first-class service has led to the expansion in the role of nurses in recent years. We present results of a comparison of the cost-effectiveness of conventional and nurse-led out-patient ear clinics. Our results indicate that cost-effective health care is a distinct competitive advantage for nurses taking up some roles conventionally performed by doctors. The difference in mean cost of out-patient visit per patient between the two groups is £75.28. This is equivalent to a reduction in cost to the hospital of more than £47000 for the 626 patients seen in a nurse-led ear clinic in a year. The nurse-led service is thus more cost-effective and presents an opportunity by freeing up otolaryngologists’ time to see more complex patients and has the potential for reducing out-patient access time in the NHS.

The aim of this study was to investigate pulsatile tinnitus as a presenting symptom in cervicocephalic arterial dissection (CCAD). Of the 136 consecutive patients with confirmed CCAD, 16 presented with pulsatile tinnitus. On admission 10 patients presented with subjective tinnitus and five with objective tinnitus, tinnitus being the only presenting symptom in one case. In one further case with bilateral ICA dissection (ICAD) subjective tinnitus appeared three months after the initial symptoms of arterial dissection, despite a contralateral cervical bruit being evident on admission. Thirteen patients presented with headache or neck pain. Ischaemic symptoms were detected in six and Horner’s syndrome in four patients. Vertigo and dysgeusia were reported in two patients each. Arterial dissection involved unilateral ICA in 11, bilateral ICA in two, unilateral vertebral artery (VA) in two and bilateral ICA and bilateral VA in one patient. In angiography the most common finding was irregular stenosis, and the majority of these abnormalities normalized during follow-up. To avoid delay in diagnosis a high index of suspicion and early angiography (digital subtraction or magnetic resonance angiography) are warranted.

Intumescentia septi nasi anterior (ISNA) is a common anatomical variation that is not routinely noticed by surgeons or radiologists. ISNA is a mucosal bulging located on each side of the anterior part of the septum. The aim of this study was to investigate the prevalence of ISNA in different ages and sexes.

In this study, computerized tomography (CT) scans of the paranasal sinus were obtained from 595 patients who had symptoms of chronic sinusitis. Among 595 subjects, ISNA was found in 332 (55.79 per cent) of subjects. It was found more frequently in males than females in every age group.

Although ISNA is a common anatomical variation, it is generally overlooked. This is the first report on ISNA in different age groups and sexes.

The objectives in treatment of bilateral vocal fold immobility (BVFI) are to achieve adequate airway, preservation of voice quality and laryngeal competence. The present prospective study was designed to evaluate precisely the efficiency and long-term clinical outcome in a series of 13 patients with irreversible BVFI, consecutively managed with endoscopic radiosurgical posterior transverse cordotomy (ERPTC). The operation was performed endoscopically using an Ellman Radiosurgical Instrument and a specially designed electrode. Pre- and post-operative inspiratory function measurements and acoustical vocal analysis were conducted on the patients and were tested for potential statistical relation to successful rehabilitation of the airway. One-step, successful restoration of the airway was achieved in all patients. The post-operative improvement of spirometric values was statistically significant (p < 0.0001), and during the follow-up period of (six to 30) months, airway stability was demonstrated in all patients. In terms of acoustic analysis a non-significant difference was found between pre- and post-operative vocal functions (p > 0.05). This management approach offers an alternative to laser procedures, it provides a ’one-stage’ solution for permanent bilateral vocal fold immobility, and avoids terminal loss of voice quality. The authors’ data confirm the safety, ease of performance, and efficiency of ERPTC in patients with bilateral immobile vocal folds.

Head and neck cancers have been described in patients with human immunodeficiency virus-1 (HIV-1) infection. However the incidence, aetiology and clinical features of the disease remain unclear.

Patients with head and neck cancer and HIV were identified from a large HIV centre. The incidence and clinical features were recorded, and the tumours were stained for Epstein-Barr virus (EBV).

Head and neckcancer occurred more frequently than in an age-matched control group (1.66 vs 0.55/10,000 patient years respectively p < 0.05). Highly active anti-retroviral therapy has not significantly altered the incidence of the disease. All of the tumours tested were positive for EBV. Patients were moderately immunosuppressed at diagnosis and had aggressive tumours. All but one of the patients died of cancer with a median survival of 28 months.

Head and neck cancer occurs more frequently in HIV. It is an aggressive disease and EBV may play a role in its pathogenesis.

This study was designed to evaluate the effects of a prophylactic antibiotic regimen on the incidence of wound infection after clean neck dissections. A prospective series of 57 patients undergoing clean neck dissections with the use of perioperative ampicillin-sulbactam for 24 hours was compared with an historical control group of 51 patients undergoing clean neck dissections with no perioperative antibiotic use. The outcome variable was the incidence of post-operative wound infection. The two groups were similar for factors reported to influence the rate of post-operative wound infection. Wound infection occurred in one patient (1.7 per cent) in the study group and in seven patients (13.3 per cent) in the control group, the difference was statistically significant (p = 0.02). These data suggest that the use of a perioperative antibiotic for 24 hours in patients undergoing clean neck dissection results in significant reduction in the incidence of post-operative wound infection.

The General Medical Council’s core curriculum model for undergraduate medical training is leading to changes in the way specialist subjects are taught. A postal survey was undertaken to evaluate the current state of undergraduate clinical teaching in otolaryngology in the United Kingdom. Data were received from all 27 medical schools. Six medical schools (22 per cent) do not have a compulsory ENT attachment, although three of these offer an optional attachment. Fifty-eight per cent of all ENT attachments are combined with other specialities including dermatology, ophthalmology and neurology. The average length of time spent with the ENT department during medical school training is one and a half weeks. Forty-two per cent of students do not have a formal assessment of their clinical skills or knowledge at the end of such attachments.

A variety of approaches have been employed for the reconstruction of head and neck defects and most of the techniques involve the use of arterialized vascular flaps alone, or in conjunction with other regional or local tissues. We frequently use a pectoralis major myocutaneous (PMMC) flap in our hospital in addition to other pedicled or free tissue transfers. A PMMC flap is a reliable flap with acceptable complications, needs a small learning curve, takes less time, and does not require additional investment (i.e. microscopes, loops etc). The disadvantages of the PMMC flap is that it has a restricted arc of rotation, gives a cosmetically unacceptable bulk in the neck, it is difficult in females and causes significant shoulder dysfunction. We have made a small improvization in the flap-raising technique which is helpful for the surgeon. This involves utilization of intestinal clamps to hold and cut the pectoralis major muscle.

Precise bimanual microsurgical excision of sessile, thin benign epithelial lesions of the vocal folds can be difficult. During microlaryngeal surgery, the potential risks of over-excision and under-excision are of major concern. We introduce a microsurgical technique using horizontally-opening curved microforceps and microscissors, instead of the conventional vertically-opening microinstruments, to remove vocal nodules and simple epithelial hyperplasia. The treatment results were satisfactory, with 208 (90.8 per cent) of patients retaining a satisfactory/normal (G0) voice. No patient had a worsened voice after the procedure. This microsurgical pressing excision technique is an alternative precise method for microlaryngosurgery.

Cutaneous meningiomas are extremely rare tumours and their diagnosis is difficult. We describe the case of a patient who developed a paranasal swelling after head trauma and associated fractures in the same region years before. Histopathological examination of an incisional biopsy revealed the diagnosis of cutaneous meningioma. After one and a half years’ follow up, surgical excision was performed because of progressive growth of the tumour and associated aesthetic problems. Extracranial meningiomas can develop probably secondary to trapping of meningeal tissue after trauma. If there is no intracranial connection surgical removal can be considered.

Tinnitus produced by middle-ear myoclonus is a rare condition. In this article, a rare case of unilateral continuous high-frequency objective tinnitus caused by middle-ear myoclonus is described. This condition appears to be the second case reported in the literature. Otoscopic examination revealed visible rhythmic movements of the tympanic membrane. Weak clicking sounds were heard around the right ear by auscultation. Direct stimulation of the soft palate showed no evidence of palated myoclonus. Tympanometry confirmed rhythmic changes in the middle-ear compliance. The condition was effectively treated with a muscle relaxant (orphenadrine citrate).

Glomus tumours of the skull base are rare, and most frequently present with symptoms of hearing loss and tinnitus. Diagnosis is often delayed due to the slow growth of the tumour. We describe the previously unreported occurrence of a glomus tumour presenting with a unilateral accessory nerve palsy.

The authors report a case of acute vagus nerve paralysis that appeared during a course of chemotherapy. The drugs had been administered through a totally implantable venous access device (TIVAD), whose catheter tip had migrated into the right internal jugular vein (IJV) and was surrounded by a complete venous thrombosis. The supposed aetiology of this paralysis was a leakage of the cytotoxic drug (5-fluorouracil) from the vessel wall into the surrounding carotid space, because of the stagnation of the chemotherapeutic agent above the thrombosis. Four months after cessation of chemotherapy, the laryngeal paralysis was still evident.

Thyroglossal duct cysts most frequently present in childhood as painless midline swellings around the level of the hyoid. Classically the cyst moves upwards on protruding the tongue. Here we report a novel case of a thyroglossal cyst in an adult in whom the history, examination and fine needle aspiration cytology were typical of a traumatic haematoma. This case is also unique because the thyroglossal duct cyst extended beyond the thyroid gland to the suprasternal notch and actually required two parallel transverse cervical incisions for its complete en bloc removal.

Migrated ingested foreign bodies from the upper digestive tract have the potential to cause life-threatening complications. Cases of spontaneous expulsion to the skin of the neck are very rare. We present an unusual case of an ingested foreign body that migrated out of the upper digestive tract and self-extruded via the skin of the neck. An approach to the safe management of such seemingly innocuous foreign bodies is discussed. This report highlights the message that unfound ingested foreign bodies should be treated seriously due to the possibility of migration and resulting complications.

Bilateral choanal atresia is potentially life-threatening. The condition almost always presents in the new born, with alternating phases of respiratory distress and apnoea relieved by crying. We report a rare case of bilateral choanal atresia presenting for the first time at 22 years of age. The patient had no features of cyanosis or apnoea, presenting only with bilateral nasal obstruction, rhinorrhoea and anosmia. His neonatal history was unremarkable. No syndromic association was noted excepting for telecanthus. The presence of bony atresia was confirmed on computed tomography (CT) scan and transnasal endoscopic surgery was used to obtain a patent airway. This case is a rare report of bilateral choanal atresia presenting for the first time in adult life.