To analyse the aetiological profile and surgical results of patients with acquired chronic subglottic stenosis, and formulate a surgical scheme based on an audit of various surgical procedures.

Thirty patients were treated by 65 procedures (31 endoscopic and 34 external) between 2004 and 2009.

Isolated subglottic stenosis was noted as unusual in the majority (27 cases), demonstrating contiguous tracheal or glottic involvement. The major aetiologies were intubation injury (n = 8) and external injury (n = 21) (i.e. blunt trauma, strangulation or penetrating injury). Vocal fold immobility and cartilage framework involvement were frequent with external injury and infrequent with intubation injury. Luminal restoration was achieved by endoscopic procedures in 2 cases, external procedures in 19 cases, and external plus adjuvant endoscopic procedures in 8 cases. The preferred surgical options were: endoscopic procedures, restricted to short, recent, grade I or II mucosal stenosis cases; and external procedures for all other stenosis situations, including isolated subglottic (anterior cricoid split plus cartilage graft), subglottic and glottic or high subglottic (anterior plus posterior cricoid split with cartilage graft), and subglottic and tracheal (cricotracheal resection with anastomosis).

External injury stenosis has a worse profile than intubation injury stenosis. Anatomical categorisation of subglottic stenosis guides surgical procedure selection. Endoscopic procedures have limited indications as primary procedures but are useful adjunctive procedures.

Tracheostomies are a common procedure within the specialties of otolaryngology and intensive care. The ENT department at Monklands Hospital has developed the position of tracheostomy clinical nurse specialist to improve the management of tracheostomy patients. There is evidence to support the development of a multidisciplinary team for the management of tracheostomy patients following intensive care unit treatment; however, the creation of a specific tracheostomy clinical nurse specialist position has not been widely endorsed in the literature.

This paper describes the role of the tracheostomy clinical nurse specialist, advocating this position within the multidisciplinary team.

To report a case of misdiagnosis of an impacted oesophageal button battery in a child, and to describe the associated risk factors for impaction and the management of such cases.

An 18-month-old, otherwise fit and well child with stridulous respiration was initially treated for croup. Medical treatment over the course of three months failed, and appropriate imaging subsequently demonstrated an impacted button battery in the upper oesophagus. This was promptly removed. There were no signs of damage on direct visualisation, or on a follow-up contrast swallow image.

This case highlights the difficulty of diagnosing oesophageal foreign bodies. We also discuss the characteristics of button batteries which confer a greater risk of impaction, and the associated sequelae and complications.

The potential efficacy of antifungal agents (e.g. Mycostatin) in treating acute attacks of Ménière's disease was first suggested in 1983 but few data have been published. Oral Mycostatin has been used as second-line medical treatment for intractable Ménière's disease at our institution for many years.

This preliminary cohort study investigated the role of oral Mycostatin in intractable Ménière's disease.

A retrospective review of patients with intractable Ménière's disease who started oral Mycostatin treatment between 2010 and 2012 was conducted.

Of 256 patients presenting with vertiginous disorders, 26 had definite Ménière's disease and had not responded to standard first-line treatment. Following oral Mycostatin treatment, improvements were reported for vertigo (n = 8), aural fullness (n = 7), tinnitus (n = 3) and subjective hearing loss (n = 3). Half of those with symptom improvement persisted with oral Mycostatin for two years and continued to remain asymptomatic.

The use of oral Mycostatin to alleviate symptoms of intractable Ménière's disease showed promising results in this case series. Mycostatin may offer a safe and useful alternative for the management of Ménière's disease for patients with chronic unremitting symptoms in whom first-line treatment options have failed.

Voriconazole is a broad-spectrum azole exhibiting strong anti-Aspergillus activity and good long-term tolerance. However, the evidence for voriconazole efficacy against refractory Aspergillus otomycosis is weak.

We reviewed the medical records of patients with Aspergillus otomycosis treated with voriconazole from January 2008 to June 2012 in a Taiwanese regional hospital. Demographic data and information regarding underlying diseases, clinical features, treatment and outcome were assessed.

In total, 14 cases of Aspergillus otomycosis were treated with voriconazole, including 5 patients with Aspergillus invasive otitis externa. All patients had failed to respond to local treatment, antibiotics or topical agents. One case was lost to follow up. The symptoms of two patients recurred after voriconazole treatment: one patient received a second 12-week course of voriconazole and was cured; and symptoms of the other patient recurred after a second 12-week course of voriconazole, leading to surgical debridement. The remaining 11 patients were cured by voriconazole treatment without extensive surgical debridement.

This study demonstrates that voriconazole can be a very effective and convenient therapeutic option for the management of refractory Aspergillus otomycosis.

To determine the prevalence of laryngeal sensory neuropathy in patients with type 2 diabetes mellitus.

A cross-sectional study was performed, comprising 50 patients diagnosed with type 2 diabetes mellitus and 36 healthy controls. In the diabetic group, glycaemic control level, disease duration and presence of neuropathy were assessed. Participants were diagnosed with laryngeal sensory neuropathy if they had a cough, globus pharyngeus or throat clearing lasting for more than six weeks, in the absence of laryngopharyngeal reflux disease, allergies, asthma, angiotensin-converting enzyme inhibitor intake or psychogenic disorders.

In the diabetic group, the mean age ± standard deviation was 44.66 ± 10.07 years. Sixty per cent of patients were male, 42 per cent had had diabetes for more than five years and 52 per cent had average to poor glycaemic control. The prevalence of laryngeal sensory neuropathy was 42 per cent in the diabetic group, compared with 13.9 per cent in controls; this difference was statistically significant (p = 0.005). There was no association between the prevalence of laryngeal sensory neuropathy and glycaemic control level, disease duration or presence of neuropathy.

Laryngeal sensory neuropathy is more common in patients with type 2 diabetes mellitus than in controls.

The successful execution of lateral osteotomies in rhinoplasty is an important step that can influence the functional and aesthetic outcome of the procedure.

This paper describes an alternative method for achieving mobilisation of the nasal bones by careful application of Walsham forceps during primary rhinoplasty.

This study examined whether the occurrence of late neck metastasis in early tongue squamous cell carcinoma can be predicted by evaluating HMGB1 (high mobility group box 1) expression in the primary lesion.

A case–control study was conducted. The cases comprised 10 patients with late neck metastasis. The controls consisted of 16 patients without recurrence. All were examined immunohistochemically for HMGB1 protein expression. The odds ratio for late neck metastasis in relation to HMGB1 was estimated.

Results for HMGB1 were dichotomised into positive staining scores (score, 5–7) and negative scores (0–4). Six cases (60 per cent) and four controls (25 per cent) were HMGB1-positive. Although no significant result was seen, compared with HMGB1-negative patients the odds ratio for late neck metastasis in HMGB1-positive patients was 3.8 (95 per cent confidence interval, 0.6–26.5) after adjusting for other factors.

In the present study, immunohistochemical study of HMGB1 in early tongue squamous cell carcinoma did not appear to be very useful for predicting occult neck metastasis. Further study is necessary to clarify the relationship between HMGB1 expression and late neck metastasis in early tongue squamous cell carcinoma.

Cricopharyngeal dysfunction following head and neck cancer treatment may lead to a significant reduction in oral intake. Carbon dioxide laser is an established procedure for the treatment of non-malignant cricopharyngeal disorders. We report our experience of laser cricopharyngeal myotomy with objective swallowing outcome measures, before and after treatment.

We identified 11 patients who had undergone carbon dioxide laser cricopharyngeal myotomy for dysphagia following radiotherapy, with or without chemotheraphy between January 2006 and July 2011. We analysed the swallowing outcomes following carbon dioxide laser cricopharyngeal myotomy by retrospective grading of pre- and post-procedure videofluoroscopic swallowing study of liquids, using the validated Modified Barium Swallow Impairment Profile.

The median Modified Barium Swallow Impairment Profile score was 13 pre-myotomy and 10 post-myotomy. This difference between scores was non-significant (p = 0.41). The median, cricopharyngeal-specific Modified Barium Swallow Impairment Profile variables (14 and 17) improved from 3 to 2, but were similarly non-significant (p = 0.16). We observed the improved Modified Barium Swallow Impairment Profile scores post-procedure in the majority of patients.

Endoscopic carbon dioxide laser cricopharyngeal myotomy remains a viable option in treatment-related cricopharyngeal dysfunction; its targeted role requires further prospective study. Objective analysis of the technique can be reported using the validated Modified Barium Swallow Impairment Profile.

To determine the effect of pterygopalatine fossa injection with xylocaine and adrenaline on: surgical field bleeding and blood loss during functional endoscopic sinus surgery for chronic rhinosinusitis, and the duration of the procedure.

A prospective, single-blinded, controlled trial was performed in a tertiary care academic centre. A total of 45 patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis, whose disease was symmetrical based on computed tomography grading, were included. A unilateral pterygopalatine fossa injection with 1 per cent xylocaine and 1:100 000 adrenaline was performed after the induction of anaesthesia. The contralateral side served as the control. The operating surgeon, who was blinded to the injected side, assessed the surgical field using a validated six-item grading system. Blood loss, blood pressure, heart rate and end-tidal carbon dioxide were recorded every 15 minutes for each side separately, and duration of surgery was noted.

There was no statistically significant difference in the surgical field grade between the injected and non-injected sides (p = 0.161). There were no differences in blood loss or duration of surgery.

Pterygopalatine fossa injection prior to functional endoscopic sinus surgery did not decrease intra-operative surgical field bleeding, blood loss or duration of surgery.

Adenoidectomy is often carried out in children for conditions such as nasal obstruction, otitis media with effusion, and obstructive sleep apnoea. Traditionally, it is performed as a blind procedure with a St Clair Thomson curette. An acceptable alternative technique is suction diathermy adenoidectomy. This study aimed to ensure that the complication rate of this latter technique was within published rates and national guidelines.

A retrospective case note review was conducted, and information regarding surgery, indications and complications was collected.

Post-operative haemorrhage was recorded for 2 of 121 patients (at days 10 and 11 post-operatively): 1 returned to the operating theatre and the other was managed conservatively. Two patients were diagnosed with infection post-operatively and managed with oral antibiotics. A further four patients re-presented with pain; in all cases, this was recorded as secondary to tonsillar fossa infection, rather than being pain related to adenoidectomy.

Given the rare but serious potential complications, the authors support National Institute for Health and Clinical Excellence guidance, which recommends that only surgeons with specific training perform this technique. By using the standard procedures for clinical governance, it is possible to ensure safe practice of even little-used techniques.

To describe a case of bilateral superior and posterior semicircular canal dehiscences, and the use of a unilateral transmastoid approach to address both right-sided defects simultaneously.

In a patient with right-sided hyperacusis, bilateral dehiscence of both the superior and the posterior semicircular canals was identified, located adjacent to the common crus, together with a right-sided, anterosuperiorly positioned sigmoid sinus and a high-riding jugular bulb. Results for audiography and cervical vestibular evoked myogenic potential testing were consistent with right-sided semicircular canal dehiscence. At surgery, a right-sided transmastoid approach provided access to plug both defects simultaneously, following posterior mobilisation of the sigmoid sinus. The patient's hyperacusis was completely resolved, with a 10–30 dB improvement in his right ear air conduction hearing, without decrement in bone conduction.

In properly selected patients, a transmastoid approach can be used to effectively manage superior semicircular canal dehiscence and posterior semicircular canal dehiscence simultaneously. Pre-operative computed tomography is recommended to evaluate the dehiscence sites and to identify complicating vascular anatomy.

This study aimed to evaluate the demographics of spasmodic dysphonia in the Indian population and to analyse the optimum dose titration of botulinum toxin type A in this group. A comparative analysis with international studies was also performed.

The study involved a retrospective analysis and audit of botulinum toxin type A dose titration in spasmodic dysphonia patients who visited our voice clinic between January 2005 and January 2012.

The average total therapeutic dose required for patients with adductor spasmodic dysphonia was 4.2 U per patient per vocal fold (total 8.4 U per patient), and for patients with abductor spasmodic dysphonia, it was 4.6 U per patient.

Our audit revealed that 80 per cent of the spasmodic dysphonia patients were male, which contrasts dramatically with international studies, wherein around 80 per cent of spasmodic dysphonia patients were female. Our study also revealed a higher dose titration of botulinum toxin for the Indian spasmodic dysphonia population in both adductor and abductor spasmodic dysphonia cases.

This study presents the incidence of denture impaction in the oesophagus, and discusses the difficulties of managing such cases.

A total of 262 patients with a history of foreign body ingestion (between 1999 and 2010) were reviewed; 46 of these patients had dentures impacted in the oesophagus.

The cervical section of the oesophagus was the commonest site of impaction. Dysphagia and tracheal tenderness were the most consistent features when dentures became impacted in the upper oesophagus. In most cases, rigid oesophagoscopy enabled successful removal of the impacted denture. Locating an impacted denture hidden within the oesophageal mucosal folds sometimes proved difficult.

In cases of impacted dentures in the oesophagus, a positive history helps in the diagnosis, but a high degree of clinical suspicion aids early detection. Conventional radiographs are important but may not always be of assistance. Early intervention reduces complications. Dentures that are poorly maintained and old are more likely to be swallowed accidentally. The inclusion of radiopaque filler within dentures would assist localisation following accidental swallowing.

Having observed variation in the breadth of surgeons' fingers whilst they are placing the incision for submandibular gland surgery, we aimed to examine this technique of incision siting, quantify the differences in fingerbreadths and consider any consequences of variability.

Surgeons trained in salivary gland surgery were questioned on their method of incision placement for submandibular gland surgery. The breadth of index and middle fingers were subsequently measured using Vernier calipers.

The majority of surgeons use a measure of two fingerbreadths below the mandible in planning their approach to the submandibular gland. There is a significant difference in the size of surgeons' fingers, particularly between men and women (mean, 4.2 cm vs 3.6 cm).

Fingerbreadth measurements are somewhat arbitrary, with significant inter-surgeon variability. However, based on the results of cadaveric studies, the findings indicate that the technique is safe for marking the incision in submandibular surgery.

To describe an unusual cause for hearing loss in an adult.

A 37-year-old man presented with a year's history of right-sided hearing loss. He had no history of trauma, or local or systemic infection. He was otherwise well, took no medication and had no allergies. He had a two-year history of low back pain. On examination, he had a retracted right tympanic membrane with no perforation, and a middle-ear effusion. Nasendoscopy was normal. Examination of other systems was unremarkable. Computed tomography of the temporal bones with contrast demonstrated a large, right, intra-cerebral internal carotid artery aneurysm compressing the eustachian tube. After a balloon occlusion test, he underwent endovascular occlusion of the parent vessel. He made a good post-operative recovery. A subsequent abdominal ultrasound excluded an abdominal aneurysm as a cause of his low back pain. His hearing had not improved three days post-operatively, and was to be formally assessed and monitored in the clinic.

A carotid aneurysm is a rare cause of eustachian tube compression but must be considered in the differential diagnosis of conductive hearing loss. Aneurysms may have systemic causes, and their presence in other systems should be excluded as they may be multiple.

Liposarcomas of the larynx and its sub-sites are rare. Within this group of tumours, well-differentiated liposarcomas of the epiglottis have been only sporadically reported. In view of its infrequent presentation, difficulty still exists over the diagnosis of this pathological entity, together with uncertainty over its exact accepted management.

We present the case of a well-differentiated liposarcoma of the epiglottis, and we review the associated English-language literature.

The reported patient underwent multiple attempts at surgical treatment prior to establishment of a firm diagnosis. In light of the diagnosis and other mitigating factors, a conservative approach was adopted.

A high index of clinical suspicion and detailed histological analysis are required when encountering a recurrent soft tissue lesion of the larynx. In the presented case, a multidisciplinary approach and conservative management plan were adopted, based on a holistic management approach and a review of the published literature.

There is currently a lack of robust evidence on the best form of packing for otological surgery. We describe the use of the absorbable gelatin sponge, a packing material that does not require removal and has the benefit of being considerably cheaper compared to other common forms of ear packing.

A comparison was made of the financial cost of several forms of packing for common otological procedures. In addition, a retrospective audit of complications was undertaken of all patients in whom the absorbable gelatin sponge was used over the past three years.

The absorbable gelatin sponge was shown to be cheaper to purchase per unit and also more economical to use. It has been the exclusive form of packing used in 519 procedures over the past three years at the William Harvey Hospital in Ashford (UK), with very few complications noted at the follow-up review.

We strongly advocate using the absorbable gelatin sponge, a packing material that is kinder to the patient, has similar efficacy to other forms of packing and is also much cheaper to use compared to other common forms of packing.

Hyperpneumatisation of the skull base and upper cervical vertebrae is a very rare condition of uncertain aetiology and pathophysiology.

A case of extensive hyperpneumatisation of the craniocervical junction and upper three cervical vertebrae is described, in a patient who habitually performed the Valsalva manoeuvre to relieve the symptoms of a patulous eustachian tube. Reported symptoms of ear, neck and shoulder pain deteriorated after minor head trauma. There was a drastic radiological and clinical improvement after ceasing to perform the Valsalva manoeuvre.

All reported cases of craniocervical bone hyperpneumatisation have in common a history of raised middle-ear pressure, minor trauma or both. We therefore suggest that chronically raised middle-ear pressure leads to destruction of bony tissue and pneumatisation, and that this process is able to cross joints into the cervical spine, either via micro-fractures following trauma, or as a result of congenital assimilation of the craniocervical junction.