The aim of this study was to systematically identify the type and severity of all comorbid conditions in a cohort of 180 patients with laryngeal squamous cancer. The authors retrospectively surveyed the notes using the Adult Comorbidity Evaluation −27 index (ACE−27) and applying a systematic process of data abstraction that had previously been shown to be accurate and reliable. The results provided insight into the distribution, site and extent of decompensation caused by comorbidity. It was found that 116 (64.4 per cent) of 180 patients in the study population had some form of comorbid illness, with the cardiovascular and respiratory systems being the top two body systems affected in 43.9 per cent and 24.1 per cent respectively. One-quarter (25.8 per cent) of these 116 patients had comorbid illnesses in more than one body system. Concurrent neurological disease is associated with high mortality. The ACE − 27 is a comprehensive instrument that codes all forms of comorbid diseases in the head and neck cancer setting excepting malnutrition. This study suggests that routine collection of comorbidity will be important in future outcomes analysis and in comparing treatment results between centres. Apparent improvements in treatment outcome following newer therapeutic modalities will have to take into account any changes in the comorbidity type and burden over time.

Electroneuronography (ENoG) has become a useful test for estimating the degree of facial nerve degeneration and predicting the prognosis in patients with facial nerve palsy. Test results may be influenced by several factors, including the electrode positions, skin resistance, stimulus magnitude, and possible artifacts. Regarding recording electrode positions, different groups have used two different locations, the nasolabial fold and nasal ala. The authors compared the waveforms recorded from these two locations in ENoG recordings to obtain the optimal waveform. Twenty healthy volunteers and 25 patients with unilateral facial nerve palsy were included in this study. Recordings were carried out with the recording electrode placed on the nasolabial fold, followed by placement on the nasal ala after 10 minutes. The following parameters were assessed: (1) the supramaximal threshold, (2) amplitude and shape of the waveform, (3) interside difference, and (4) test-retest variability. There was no significant difference in the amplitude of the waveform, interside difference, and test-retest variability between the two groups. However, when the electrode was placed on the nasal ala, the threshold was significantly lower, an ideal biphasic configuration was present in almost all cases (97.5 per cent) of normal volunteers and it was easier to identify the waveform. Placement of the recording electrode on the nasal ala would be the preferred method.

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.

Nasal continuous positive airway pressure (CPAP) is the mainstay of treatment for patients with moderate to severe obstructive sleep apnoea (OSA). However, tolerance and compliance are poor.

An audit using the Christchurch Hospital ORL surgery database identified patients who underwent upper airway surgery for OSA. Tracheostomy and bimaxillary advancement patients were excluded. Adults with moderate to severe OSA (Desaturation Index (DI) >10 n.h-1), who had failed atrial of nasal CPAP, and had pre-operative and post-operative sleep study data were identified. Objective (DI) and Subjective (Epworth Sleepiness Score (ESS)) outcome measures were recorded.

The database identified 69 patients who underwent surgery for snoring or OSA; of these, 25 patients formed the study group. Sixteen out of 25 improved (64 per cent) after surgery, seven out of 25 showed no change (28 per cent), two patients (eight per cent) showed deterioration in their DI. Forty-eight per cent of patients had >50 per cent post-operative improvement in DI. Fourteen out of 25 (56 per cent) had a post-operative DI <20 n.h-1. Seven out of 25 (28 per cent) had a post-operative DI <10 n.h-1. Upper airway surgery has a role in the managementof selected patients with OSA who cannot tolerate nasal CPAP.

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.

Introduction: Although branchial cysts may present as asymptomatic swellings, about one-third present acutely due to inflammation. The use of fine-needle aspiration biopsy (FNAB) and computerized tomography (CT) is controversial. The treatment of inflamed cysts is also controversial.

Aims: To compare the findings of FNAB and CT between cases of branchial cysts presenting as an asymptomatic swelling, and those presenting acutely due to inflammation, and to examine the management of infected cysts.

Materials and methods: Retrospective review of the medical records of 39 adult patients with histologically proven branchial cysts treated by the senior author (C.V.T.) between 1994 and 2003.

Results: Twenty-eight patients presented with an asymptomatic swelling. Eleven presented acutely with inflammation. A higher incidence of indeterminate fine needle aspirates and atypical CT features were found in the inflamed group. Initial treatment in the infected group consisted of intravenous antibiotics, followed by aspiration or surgical exploration in non-resolving cases. Interval excision after six weeks was performed in all inflamed cases without complication.

Conclusions: FNAB is recommended in all cystic neck lumps to rule out malignancy, but may be inconclusive, especially in inflamed cysts. Inflamed cysts are best treated with intravenous antibiotics, with or without aspiration or incision and drainage, followed by interval excision.

The quantitative relationships between the position of the mastoid segment of the facial nerve, mastoid pneumatization and the positions of neighbouring structures are undetermined. Using high resolution computed tomography (HRCT), the positions of these structureswere measured in 66 normal temporal bones. A new method for measuring the volume of pneumatization in the temporal bone based on the serial digital images of CT was designed. The method of partial correlation analysis was used to find the real relationship of the two variables. The results suggest that the factors that influence the position of the mastoid segment of the facialnerve are complicated and multiple. The development of the cranium including the temporal bone,the temporal bone pneumatization and the variable position of the jugular bulb are considered to be important factors.

Although it is widely believed that management of the airway is difficult in surgery for retrosternal goitre, a review of the literature, revealing management of 1969 patients with retrosternal goitre, provided scant evidence of difficult intubation or post-operative tracheomalacia resulting in tracheal collapse. This was reflected in our own series of 18 thyroidectomies for retrosternal goitre performed at our hospitals.

This paper assessed 300 surfboard riders, comprising 229 males and 71 females to determine the prevalence and rate of growth of exostoses in this population. A group of cold water swimmers and a control group were also examined.

Significant obstruction, defined as two thirds or more occlusion of the ear canal was noted in 90 of the male surfers and 10 female surfers. This degree of occlusion was found in seven of the 32 cold water swimmers.

A male surfer who has surfed regularly for 20 years or more has a one in two chance of developing significant obstruction of the external ear canal resulting from exostoses and this is a three in seven chance for females.

Congenital sinuses arising from the pyriform fossae are rare. They may present as neck cysts, recurrent neck abscesses, thyroiditis or neonatal stridor. Children typically undergo multiple surgical procedures before the diagnosis is made.

We present our recent experience of five third-pouch sinuses and four fourth-pouch sinuses, including one bilateral case. The median age at presentation was four years. The mean number of operations prior to diagnosis was six (range 0-13), with a mean delay to diagnosis of six years. The diagnosis was made by barium swallow, by ultrasound, at pharyngoscopy or at open surgery. The median age at definitive surgery was 10 years. Definitive treatment involved complete excision of the sinus and neck mass in seven cases. Two sinuses were treated with endoscopicdiathermy to their internal opening.

Adoption of the correct nomenclature, diagnostic tools and operative requirements for these cases will help reduce the significant morbidity.

Many operative procedures have been described to treat frontal sinus disease with varying results. Obliteration of the frontal sinus is attempted when drainage procedures fail. Most large series of patients undergoing sinus obliteration have reported recurrent disease yet the management of these patients is rarely discussed. We believe Riedel’s procedure has an important role in the management of these patients. Riedel’s procedure can help eradicate frontal sinus disease and symptoms when drainage and obliteration have failed and where there is persistent disease involving the anterior wall of the frontal sinus or the sinus itself. Whilst cranialization has a role in the removal of the mucosa or contents of the frontal sinus in craniofacial resection, the morbidity associated with it make Riedel’s procedure preferable for dealing with chronic infection or locally invasive disease. Riedel’s procedure also maintains a barrier in the form of the posterior wall of the frontal sinus and the intracranial contents. Post-operative disfigurement, the main criticism of this procedure, can be reduced to some extent by chamfering the margins of the frontal sinus along with the supraorbital rims and reconstructing the anterior wall at a later date if necessary. The authors are aware that any report about frontal sinus surgery should be judged after several years follow-up, and whilst not all these cases have been asymptomatic for a decade, several have been reviewed for many years.

Objectives: We studied the experimental use of Seprafilm, a sheet-like filmform of hyaluronic acid, in the repair of subtotal perforations of the tympanic membrane (TM), and the durability of such repairs.

Method: The research was conducted on 42 Sprague–Dawley rats. Right TMs of all rats were subtotally and thermally perforated in the same fashion. Seprafilm was applied to the perforated TMs of the 21 rats comprising the experiment group. The perforated TMs of the remaining 21rats, the control group, were left to heal spontaneously.

Results: The mean healing times were recorded as 7.8 ± 0.6 days for the Seprafilm group and 14.9 ± 1.1 days for the control group (p < 0.001).

Conclusions: These results suggest that Seprafilm may be a possible first choice (before thedecision to operate) in subtotal perforations, considering its easy application and patient follow-up.

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.

Otolaryngological manifestations of acid reflux include a wide range of pharyngeal and laryngeal symptoms; and the constellation of symptoms has been called laryngopharyngeal reflux.

This is a prospective study in a cohort of patients with various throat symptoms suggestive of laryngopharyngeal reflux (LPR) who underwent flexible oesophago-gastroscopy, as a principal investigation. The aims were to look at the most reliable symptom(s) and sign(s), the diagnostic role of flexible oesophago-gastroscopy and the treatment response in these patients.

The endoscopy score of 0 to 3 was based on endoscopic findings and the treatment response was measured from 0 to 100 per cent improvement of symptoms, as described by the patients.

There were a total of 303 patients, 174 females and 129 males with ages ranging from 19 to 88 years. Seventy-five per cent had had symptoms for more than a year. Fifteen per cent were smokers. Globus, voice change, sore throat, dysphagia and cough were the predominant symptoms. Most patients, however, presented with a complex of various other secondary symptoms.

The endoscopic findings were abnormal in 98 per cent of patients. Apart from the finding of non-specific hyperaemia, usually of the posterior larynx (13 per cent), lesions of the larynx and vocal folds were surprisingly uncommon.

Proton pump inhibitors (PPI) were prescribed in 90 per cent of patients. A total of 233 (76.8 per cent) responded to treatment. The improvement of symptoms ranged from 25 per cent in 36 (23 per cent), 50 per cent in 60 (20 per cent), 75 per cent in 59 (19 per cent) and 100 per centin 78 (26 per cent) patients.

Accumulative analysis of variance showed a significant difference between treatment responders and non-responders (p <0.04). In a logistic regression model patients with globus, voice change and gastric prolapse were more likely to respond to treatment (p <0.04).

It can be concluded that voice change, sore throat, globus and cough choking are the most reliable symptoms of laryngopharyngeal reflux. Voice change and globus symptoms can be of predictive value in terms of successful treatment response. Flexible oesophago-gastroscopy (FOG) isa simple, safe and reliable way of assessment in these cases and treatment with PPI can be effective in the majority of patients.

The principal reason for performing investigations in patients with globus pharyngeus is to detect a pharyngeal or upper oesophageal malignancy presenting this way. There is uncertainty regarding both the necessity for investigation in globus patients and the first line investigation of choice in the screening of such patients. The authors therefore undertook a retrospective study of 699 patients who presented with globus sensation. Of these, 451 patients (64.5 per cent) had a typical history and in these patients, outpatient examination, including fibre-optic nasendoscopy was able to detect all pathologies, except one insignificant pharyngeal pouch, which required no intervention and one patient with a distal peptic stricture. In patients with atypical symptoms the combination of fibre-optic nasendoscopy and barium swallow identified all pathologies (five aerodigestive tract malignancies) except one distal peptic stricture. The authors concluded that if out-patient examination is adequate, no further investigation of typical globus symptoms is required. Such a policy would produce significant savings for both out-patient and radiology services.

Residual or recurrent nasopharyngeal carcinoma (NPC) is usually managed by re-irradiation or salvage surgery. This case presented a residual NPC with limited extent and an accessible location in the nasopharynx after completion of sequential chemoradiotherapy. The lesion was completely resected via the transpalatal route under endoscopic visualization with no significant post-operative morbidity. This is the first report of NPC successfully treated by this type of surgery.

This study evaluated the efficacy of the modified endoscopic Lothrop procedure (MELP) for complicated frontal mucoceles and endoscopic marsupialization for other paranasal sinus mucoceles.

It was a retrospective, consecutive case review of sinus mucoceles treated endoscopically by a single surgeon over a four-year period (1998-2002).

There were 41 mucoceles in 28 patients, including 24 frontal, eight frontoethmoidal, three ethmoidal, five maxillary and one frontal mucocele. Twenty-one patients underwent the modified Lothrop procedure for frontal mucoceles, and seven underwent simple drainage and marsupialization for frontoethmoidal, ethmoidal and maxillary mucoceles. At median follow-up of 16 months, all patients had a patent mucocele opening. Patients treated by drainage and marsupialization did not have any complications or mucocele recurrence. All patients treated by the modified endoscopic Lothrop procedure had improvement in symptoms and signs. Four patients had minor complications including epistaxis and adhesions and five required further surgery. The average hospital in-patient stay was 2 ± 1.4 days.

Endoscopic techniques, including MELP are effective in the short term for the management of complex and simple paranasal sinus mucoceles. MELP has a useful place in the management of mucoceles with a significant bony partition from an adjacent sinus or nasal cavity. It is also indicated when the mucocele is associated with loss of lateral support in the sinus with risk of medial-wall collapse of the orbital contents obstructing drainage.

Treating laryngopharyngeal reflux is the most accepted treatment for laryngeal granulomas. However, response to this treatment is prolonged and in some cases persistent. The authors hypothesize that this is due to the continuous trauma to the mucoperichondrium fromadduction of the vocal folds thus preventing regeneration of healthy mucosa.

A prospective study was performed on six patients with laryngeal granulomas failing prolonged laryngopharyngeal reflux treatment, speech therapy, and surgical excisions. Botulinum toxin Awas injected into the affected thyroarytenoid to reduce adduction trauma. Video-stroboscopy wasused to assess response.

A 50 per cent reduction in the size of the granulomas was noted within two weeks with a complete and permanent response within two to eight weeks in five out of six patients. One patient had an obstructing pyogenic granuloma that required excision and recurred after excision but responded to a repeated injection.

The addition of a single injection of botulinum toxin A to the standard treatment expeditiously eliminated persistent and recurrent laryngeal granulomas.

Atrophic rhinitis is a chronic inflammatory disease of the nose, which is more common in India. Chronic dacryocystitis is its rare complication. The authors found four cases of chronic dacryocystitis from March 2002 to October 2003 due to atrophic rhinitis. It was diagnosed clinically by the regurgitation test and lacrimal syringing. These cases were treated conservatively for a period of six weeks to make the nasal mucosa healthier and were then subjected to endoscopic dacryocystorhinostomy (end-DCR) under local anaesthesia. The procedure was found to be more difficult due to bleeding and the healing time was prolonged as compared to other cases of end-DCR. After one to one and half years of follow-up the primary success rate was 75 per cent but after revision surgery in one case, all cases were successful. Hence it was concluded that atrophic rhinitis is no more a contraindication for end-DCR. However, meticulous initial preparation and post-operative follow-up is necessary to improve the result.

This study evaluates the efficacy and systemic tolerability of licensed doses of mometasone furoate (Nasonex®) and betamethasone sodium phosphate (Betnesol®) in allergic chronic rhinosinusitis patients. It also assesses the diagnostic accuracy of morning salivary cortisol (MSC) concentrations to screen for adrenal suppression inthese patients.

Forty-eight patients were prospectively randomized to two treatment limbs. Symptom scores and adrenal function assessments were performed immediately prior to commencement and at the end of treatment.

One (4 per cent) mometasone furoate and 14 (58 per cent) betamethasone sodium phosphate patients developed biochemical evidence of adrenal suppression. There were statistically significant (p < 0.005) reductions in symptom scores following treatment, but no significant difference (p > 0.05) between the drug groups regarding post-treatment symptom scores. As a screening tool for iatrogenic adrenal suppression, MSC had a sensitivity of 100 per cent and a specificity of 97 per cent.

This study demonstrates the high risk of developing adrenal suppression secondary to betamethasone sodium phosphate therapy. The salivary cortisol assay is an accurate tool for monitoringadrenal function and is ideally suited to the out-patient setting.