To describe a novel technique of delivering mitomycin C safely via endoscopic sinus surgery.

Mitomycin C was applied in the median frontal drainage pathway of a 44-year-old woman suffering from recalcitrant chronic frontal sinusitis. The mitomycin C was soaked onto a neurosurgical patty, which was delivered through a nasopharyngeal tube trimmed to ensure delivery directly to the desired area, thus sparing adjacent mucosa.

Mitomycin C has been suggested to have a useful role in reducing post-operative scarring after endonasal surgery. The long term safety of topical mitomycin C is not yet known, and inadvertent topical application to adjacent mucosa should be avoided. The described technique achieves this in a simple manner, and can be easily applied to other locations.

Nasogastric tube insertion is often difficult, due to a variety of reasons, e.g. skewed laryngeal anatomy. We present a previously unreported method of facilitating nasogastric tube insertion, using a flexible nasendoscope.

The nasogastric tube is anchored to a flexible nasendoscope using sodium alginate dressing ties. The nasendoscope is then passed into the upper oesophagus, along with the nasogastric tube. Once the nasogastric tube has passed the cricopharyngeus, gentle traction on the nasendoscope releases it from the nasogastric tube. The nasendoscope can then be withdrawn. A previous safety study of sodium alginate ingestion showed no adverse effects.

This method enables nasogastric tube insertion under direct vision, and allows the tube to be guided past the larynx and into the upper oesophagus.

We report a case of an arteriovenous malformation within the internal auditory meatus and cerebellopontine angle, and we discuss its imaging appearances and management.

A 50-year-old man presented with a two-year history of vertigo. Magnetic resonance imaging and magnetic resonance angiography demonstrated a lesion consisting of multiple ‘high flow’ vessels within the left internal auditory meatus and cerebellopontine angle. Transarterial embolisation was performed, with obliteration of the arteriovenous malformation.

Arteriovenous malformations of the internal auditory meatus and cerebellopontine angle are exceedingly rare. It is important that a pre-treatment diagnosis is made, as the management of arteriovenous malformation differs from that of other, more common lesions at this site.

We report the first case in the English language literature of an adamantinomatous infrasellar craniopharyngioma, and we describe our management strategy.

A 46-year-old woman presented with a six-month history of left-sided nasal obstruction and epistaxis. Rhinological examination revealed a left-sided, polypoidal lesion lying medial to the middle turbinate. An urgent examination under anaesthesia was organised; biopsies were considered characteristic of craniopharyngioma. Magnetic resonance imaging and computed tomography demonstrated a well defined, heterogeneous, infrasellar mass centred in the midline, extending anteriorly into the left nasal cavity and posteriorly encasing both internal carotid arteries. Craniofacial resection was performed via a midfacial degloving approach, with adjuvant radiotherapy. The patient was disease-free one year post-operatively.

Craniopharyngiomas should be considered in the differential diagnosis of a unilateral nasal polyp. Although technically benign, they are locally aggressive. Therefore, we recommend complete excision with adjuvant radiotherapy if margins are involved or close.

To refine the case selection process for the ‘cucumber’ mounting system for laryngeal biopsies.

We conducted a retrospective audit of cucumber technique specimens taken between January 2002 and December 2008. We analysed the clinical indications for biopsy and the pathological diagnosis, for each specimen, in order to inform our case selection process.

The cucumber technique was used for 125 laryngeal specimens. 60 specimens were taken for diagnostic sampling, 46 were taken during endoscopic laser resection, and 19 for overtly benign pathology. The cucumber technique was most useful for the interpretation of margins in endoscopic laser resection specimens.

The cucumber technique is most useful for endoscopic resection cases in which tumour, dysplasia or suspicious lesions have been excised. Detailed information on resection margins is invaluable during multidisciplinary team discussions on patient management. Detailed photography of mounted specimens enables both laryngologist and pathologist to orientate and interpret specimens accurately.

Only a few benign tumours of the middle ear have been reported to lead to the development of facial palsy. Here, we describe a patient with middle-ear cavernous lymphangioma and facial palsy.

Single case study.

A 61-year-old man presented with left-sided hearing impairment and incomplete left facial palsy. A tumour was confirmed to be occupying the epi- to mesotympanum and to be joined to the facial nerve. The tumour was removed along with facial nerve tissue, which was resected at its horizontal portion, and the remaining facial nerve was fixed by end-to-end anastomosis. Complete facial paralysis occurred after the operation, but the patient's House–Brackmann grade gradually improved to grade III. Post-operative histopathological examination revealed infiltration of the lymphangioma into the facial nerve tissue, together with mild neural atrophy of the facial nerve.

These findings suggested that tumour invasion was the cause of facial palsy in this patient.

We report a case of an Oestrus ovis larva which developed into the second larval stage within a healthy, immunocompetent human, and we review the relevant literature.

Clinical case report and Pubmed search of reports of human nasal myiasis due to Oestrus ovis, especially those describing the larval stage.

Humans are not normally hosts of the sheep nasal bot fly, but infestations by its larvae have been described. The eye is the most common site, but larvae have occasionally been found in the human nose. Transformation of larvae into the second and third stages, within the human nose, is even more uncommon.

To the best of our knowledge, we report the first Swedish case, and the third case world-wide, of Oestrus ovis larval development beyond the first larval stage, within an immunocompetent, healthy human.

Patients with squamous cell carcinoma of the head and neck constitute a high risk group for synchronous and metachronous tumours.

This study aimed to investigate the usefulness of white light and autofluorescence bronchoscopy in the evaluation of pre-malignant and early neoplastic lesions in patients with laryngeal cancer, who are at high risk of concomitant lung cancer.

This prospective, cross-sectional study included 30 patients who had undergone total laryngectomy for squamous cell carcinoma of the larynx. The tracheobronchial system was investigated for the presence of pre-malignant and malignant lesions, using a combination of white light and autofluorescence bronchoscopy. Biopsies were obtained from areas with a pathological appearance, and histopathological studies were performed.

All patients had a permanent tracheostomy. Light and autofluorescence bronchoscopy indicated that the tracheobronchial system was normal in 11 patients. A total of 27 biopsies was taken from the remaining 19 patients, and revealed invasive squamous cell carcinoma in one patient and pre-malignant changes in six.

Bronchoscopy is a valuable and practical tool for screening patients at high risk of lung cancer, and requires minimal intervention especially in patients with a permanent tracheostomy. Of the various bronchoscopic techniques becoming available, autofluorescence bronchoscopy shows promise for the detection of pre-invasive malignant changes of the tracheobronchial system in patients previously operated upon for laryngeal cancer.

We report two cases of nasal natural killer T cell lymphoma which presented atypically following surgical intervention.

Two patients with a previous history of endoscopic nasal surgery presented with progressive facial swelling and necrosis. The histology of several nasal biopsies was suggestive of acute, necrotising inflammation. Considering these patients' midline destruction of the nose and face, and their inconclusive biopsies, immunohistochemical studies were undertaken, enabling the diagnosis of peripheral natural killer T cell lymphoma.

Natural killer T cell lymphoma of the sinonasal tract is an important differential diagnosis of destructive lesions of the nose and midface. The definitive diagnosis is often delayed. Hence, this tumour should be considered in patients with atypical presentations of acute inflammation following surgical intervention; such patients should be thoroughly investigated. Early immunohistochemical investigation is needed to enable prompt diagnosis in suspicious cases.

Precise delineation of the extent of frontal sinus pneumatisation is a crucial step in osteoplastic flap frontal sinus surgery. The authors present a novel method of achieving this objective.

First, models of the frontal area are generated using three-dimensional printing based on pre-operative computed tomography image data. These models are then used to create an onlay template of the frontal sinus, which is used intra-operatively.

In a series of 10 patients undergoing osteoplastic flap frontal sinus surgery, the described frontal sinus templates were consistently accurate to within 1 mm.

Frontal sinus templates are potentially useful adjuncts to current techniques employed to guide frontal sinus surgery.

The authors discuss a case of conjunctival irritation and epiphora in a patient who had undergone dacryocystorhinostomy three years earlier.

Case report, and a review of the world literature concerning lacrimal canalicular air regurgitation after dacryocystorhinostomy.

A 70-year-old woman, who used continuous positive airway pressure therapy during sleep, complained of epiphora and conjunctival irritation. She had undergone dacryocystorhinostomy three years earlier. Her right eye had an augmented tear meniscus, with a predominantly medial conjunctival irritation. Conjunctival irritation from lacrimal canalicular air regurgitation was diagnosed. White petrolatum and mineral oil ophthalmic ointment was prescribed, applied topically before sleeping. After one month of treatment, complete relief of symptoms was obtained.

There is little current information on managing such patients. It is imperative to discuss this potential complication when considering nasolacrimal surgery in patients using continuous positive airway pressure therapy.

To report microvascular decompression as a possible effective treatment for patients with nervus intermedius neuralgia, and to contribute to the literature regarding both this syndrome and this specific form of treatment.

Case report of a patient with intermedius neuralgia. The main complaint was severe otalgia in the area innervated by the nervus intermedius, possibly caused by neurovascular compression of the nervus intermedius by the anterior inferior cerebellar artery. Microvascular decompression was undertaken, with good results.

Post-operatively, the patient felt immediate and total relief of her otalgia, with normal facial nerve function and no otological morbidity. One year post-operatively, she was still free from otalgia.

Patients with nervus intermedius neuralgia who do not respond to medical treatment may benefit from microvascular decompression.

We describe a rare case of spontaneous temporomandibular joint herniation into the external auditory canal, and we also review the presentation, aetiology and management of such cases.

An 87-year-old woman presented with a four-month history of left-sided otorrhoea and otalgia. Examination revealed a soft, polypoid mass in the left ear canal. When the patient opened her mouth the lesion disappeared. Subsequent computed tomographic imaging of the patient's temporal bones confirmed an 8.6 mm defect in the antero-inferior portion of the left ear canal, with herniation of retrodiscal soft tissues.

The external auditory canal is intimately related to the temporomandibular joint, separated only by its bony anterior wall. Neoplasm, trauma or inflammation in this area can result in displacement of the temporomandibular joint into the ear canal; however, spontaneous herniation is rare. Persistence of the primitive foramen of Huschke can result in dehiscence of the anterior canal wall, allowing articular tissue to prolapse into the ear canal. Surgical closure of these defects is known to be effective in ameliorating symptomatic cases.

Neonates are obligate nasal breathers, and nasal obstruction may have serious implications. We present an extremely rare cause of neonatal nasal obstruction, and its management.

An eight-day-old neonate was referred for upper airway obstruction. Initial investigations had identified no obvious cause. Rigid airway endoscopy revealed a large, cystic lesion appearing to arise from the roof of the posterior nasal space. Computed tomography and magnetic resonance imaging indicated a basal cephalocoele projecting inferiorly into the oropharynx, with an intracranial connection to the pituitary fossa. Histology showed fibrovascular tissue lined on one aspect by respiratory type epithelium, with mucous glands present. The tissue contained multiple cystic spaces lined by choroid plexus epithelium, with glial tissue present in the walls of the mass. A transpalatal excision of the nasopharyngeal cephalocoele, with closure of the intracranial connection, palatal repair and lumbar drain placement was undertaken. Post-operative recovery was uneventful, with no evidence of cerebrospinal fluid leakage or palatal dysfunction.

This surgical approach gave excellent access whilst avoiding the obvious morbidity associated with an intracranial approach. Nasal masses should be considered in the differential diagnosis of neonatal respiratory distress due to nasal obstruction.

Cylindrical cell papillomas are rare tumours which usually arise in the sinonasal region.

We report a case of a nasopharyngeal cylindrical cell papilloma in a 56-year-old man who presented with a four-month history of right-sided hearing loss, otalgia, vertigo and tinnitus. Investigation revealed a soft, nodular lesion obstructing the pharyngeal opening of the right eustachian tube; this was treated by wide endoscopic excision.

Cylindrical cell papilloma is a possible cause of eustachian tube obstruction in adults. Effective treatment of these lesions usually requires wide endoscopic excision, in order not to miss coexistent carcinoma.

Cerebrospinal fluid leakage is the most common complication of endoscopic trans-sphenoidal pituitary surgery. However, there is no uniformly accepted way of managing this complication when it occurs intra-operatively. This paper describes a quick, simple technique, involving layered fibrin glue and gelatin sponge, which does not compromise post-operative patient follow up.

Retrospective review of all endoscopic pituitary surgery cases conducted at a single institution since the introduction of this technique in 2002.

A total of 120 endoscopic pituitary operations were performed (96 primary procedures and 24 revisions). All intra-operative cerebrospinal fluid leaks were managed using the described method, with a failure rate of 3.6 per cent. The overall post-operative leakage rate was 1.7 per cent.

This simple, conservative technique avoids the need for further dissection and the use of non-absorbable foreign material, and has a low incidence of post-operative cerebrospinal fluid leakage.

People suffer unique health problems in high altitude areas, due to such factors as elevation, aircraft ascent and descent, extreme cold, hypoxia, hypobaria, and low relative humidity. This study was conducted to evaluate ENT morbidity at high altitude.

Serving soldiers introduced to a high altitude environment who presented with various ENT symptoms were examined to identify ENT disease. In addition, patients undergoing hyperbaric chamber therapy, tracheostomy and treatment of cold injuries were also examined for ENT problems.

The following were detected: 13 cases of otic barotrauma, 11 cases of sinus barotrauma, three cases of vertigo, six cases of pinna frostbite, three cases of barotrauma caused by hyperbaric chamber therapy, an unusually high incidence of epistaxis, and innumerable patients with high altitude pharyngitis.

Diseases of the ear, nose and throat contribute significantly to high altitude morbidity. In a military context, health education of troops is necessary to avoid such problems.

To report a patient with Pendred syndrome who developed life-threatening hypokalaemia as an unpredicted consequence of implant-induced imbalance and alcohol dependency, leading to multiple cardiac arrests.

Addenbrooke's Hospital, Cambridge, UK.

Case report and review of the English language literature concerning Pendred syndrome and cochlear implantation in Pendred syndrome patients.

Pendred syndrome is an autosomal recessive disorder which mainly affects the inner ear, thyroid and kidneys. It accounts for 10 per cent of syndromic hearing loss cases. The majority of Pendred syndrome patients are referred to cochlear implant programmes for hearing assessment and therapy. They may also have an underlying metabolic abnormality which is not clinically apparent.

Providing cochlear implants to patients with Pendred syndrome demands extensive knowledge of this condition, in order to avoid potential morbidity.

Nasopharyngeal tuberculosis is a rare condition, even in endemic tuberculosis areas. We report a case of primary nasopharyngeal tuberculosis from a non-endemic area, which presented with symptoms resembling exacerbation of previously diagnosed chronic rhinosinusitis.

A 48-year-old man presented with extreme postnasal drip and an unpleasant nasal odour. Endoscopic examination revealed irregular thickening of the left lateral and posterior wall of the nasopharynx, partially covered with crusts and necrotic tissue. Histopathological study showed typical giant cell epithelioid granulomas with caseous necrosis. Direct examination after Ziehl–Neelsen staining was positive for tuberculosis. After six months of antituberculous triple therapy, endoscopic examination revealed a completely normal nasopharynx.

To our best knowledge, this is the first published report of primary nasopharyngeal tuberculosis in a patient previously diagnosed with chronic rhinosinusitis. The difficulties in obtaining a proper diagnosis in such a case are discussed.