Guillotine tonsillectomy was the widely practised technique of tonsillectomy in the late 19th century as it was considered a quick and reliable method of removing tonsils. It fell into disrepute in the early 20th century. This paper reviews the history of the origin of the tonsillotome and traces the various modifications over the last few centuries. The current practice of guillotine tonsillectomy is examined by means of a postal questionnaire surveyof all UK consultants.

Fliess, an ENT surgeon, was Freud’s closest friend and confidant. They both believed that sexual problems were the chief cause of neurosis. Fliess postulated that eflex nasal neurosis was based on the important physiological connection between the nose and the genitals. He described specific genital spots located on the nasal inferior turbinate. Fliess’ second preoccupation was with vital periodicities. He believed that the symptoms of his reflex nasal neurosis followed regular 28-day cycles as does menstruation. He further proposed a male 23-day menstrual cycle, that he centred specifically on the nasal turbinate. Clearly, Fliess’ fanciful theories of neurosis based on the turbinates have never held any scientific validity and are presented for their curiosity. This eccentric rhinolaryngologist, however,exerted a profound influence on Freud’s conception of human development, that is often undervalued.

The aim of this study was to determine the effect of surgical approach, intact canal wall (ICW) or canal wall down (CWD), upon the success of revision surgery for chronicotitis media (COM). A retrospective analysis of 367 patients (including 65 children aged <15years) who underwent revision tympanoplasty because of persistent disease was performed. Single-staged tympanoplasty was performed, preserving the canal wall when present. Hearing was reconstructed with allograft incus. Follow-up ranged from one to 15 years. Hearing was determined by pre- and post-operative air-bone gaps.

Post-operative re-perforation, aural discharge and/or cholesteatoma rates were similar for CWD and ICW. Cholesteatoma could present following the revision, even though it was not apparentat surgery. Following tympanoplasty, the final hearing was not significantly affected by the surgical approach or presence of cholesteatoma. Improvement in hearing was adversely affected by cholesteatoma or an absent stapes suprastructure.

Revision ICW and CWD operations were both successful in controlling signs of COM. Cholesteatoma is a peripheral risk in COM and may become apparent after revision surgery.

Patients with symptomatic septal perforations require treatment, with many surgeons advocating primary treatment with an obturator if conservative measures fail. Twenty nasal Button Outcome Questionnaires were sent to patients who had undergone insertion of a septal button between 1990 and 2000 in our unit. Fourteen questionnaires were returned. This study reveals that despite a reduction in symptom score in nine patients, septal buttons are poorly tolerated by patients with only 45 per cent of obturators ultimately being in situ. In view of these findings, patients are now offered a choice between primary surgical and mechanical closure in our unit.

Proper selection of an osteotome for nasal osteotomy is important for minimizing soft tissue trauma. Radiographic analysis of the facial bony lateral wall thickness was performed to suggest a guideline for an appropriate osteotome size for Asians. Facial bone computed tomography (CT) of 100 patients (50 male, 50 female) were studied. The thickness of the facial bony lateral wall at three points along the track of a lateral osteotomy, and two points along the track of a medial osteotomy and intermediate osteotomy were measured. The average bony thickness along the track of a lateral osteotomy was 2.61 ± 0.66 mm at the low level, 2.75 ± 0.76 mm at the middle level, and 2.72 ± 0.53 mm at the high level in subjects. The average bony thickness along the track of an intermediate osteotomy were 1.26 ± 0.34 mm at the low level, and 1.31 ± 0.32 mm at the high level in the subjects. The average bony thickness along the track of the medial osteotomy were 2.54 ± 0.31 mm at the lowlevel, and 2.77 ± 0.30 mm at the high level in subjects. These results may provide a guideline for choosing an osteotome of appropriate size for the Asian population.

The measurement and achievement of improved patient benefit following a particular medical or surgical intervention has become an increasingly relevant part of the provision of effective healthcare.

We have retrospectively analysed patient satisfaction in 56 patients following rhinoplasty via the Glasgow Benefit Inventory (GBI), 25 of whom underwent pre-operative computer imaging planning. We have also audited patient reaction to this technique via a concurrent questionnaire in those subjects who underwent imaging, and correlated this with overall patient outcome.

Patient satisfaction with cosmetic rhinoplasty following computer imaging was significantly improved compared to those patients who did not receive imaging.

Despite advances in the development of voice outcome measures, there is no methodology to define and quantify the elements of the complex process of speech therapy. The components of therapy given by one therapist to the intervention limb of a controlled trial werecharacterized according to a list of five minutes. The intervention was of proven benefit compared with a control period of observation. Indirect approaches comprised two thirds of therapy time. The types and duration of intervention were assessed but no treatment category seemed moreassociated with a favourable outcome. The design shows that it is possible to perform a prospective, structured analysis of the components of voice therapy. The method appears viable for thefuture comparison of the widely varying techniques current in voice therapy practice.

Endoscopic laser treatment was performed in 43 patients with pre-malignant or malignant vocal fold epithelial lesions, 10 were treated with endoscopic laser surgery for dysplasia, 12 for carcinoma in situ (CIS), five for verrucous carcinoma and 16 patients for squamous cell carcinoma (SCC). Thirty-two patients received laser therapy as their first therapy, whereas 11 patients had had previous radiation therapy for laryngeal carcinoma (n = 9) or CIS (n = 2).

Recurrence after initial laser therapy necessitating re-treatment (a second laser treatment or radiotherapy) occurred in nine out of 32 patients (28 per cent), thus 23 (72 per cent) were maintained free of disease during the follow-up period.

Besides the 32 patients without previous therapy, patients who had already undergone radiat on therapy were also included in this study. In this group there were nine patients with SCC, one patient with CIS and one with dysplasia. They all underwent laser therapy. Four were free ofdisease during follow-up (36 per cent) and seven developed recurrences. Six (58 per cent of allpatients with previous radiation therapy) underwent total laryngectomy.

Percutaneous tracheostomy is a procedure frequently carried out in a critical care setting. It is performed in the majority of cases by anaesthetists in the United Kingdom. The ENT surgeon is only called in situations where it is deemed by the intensivist that percutanous tracheostomy would prove too great a risk. In this situation the patient was taken to the operating theatre for a surgical tracheostomy. In our paper, a retrospective analysis was performed of all percutaneous tracheostomies carried out by ENT surgeons in the Royal Glamorgan Hospital, during a two-year period from July 1999 to July 2001, to assess whether percutaneous tracheostomy is a feasible option as a first line procedure in all elective tracheostomies. Thirty-six patients were included in the study. The mean age was 60.2 years. Haemorrhage was noted to be a problem in only one patient and two patients developed post-operative wound infection that was treated with systemic antibiotics. No other complications were encountered. We propose that all ENT surgeons should be trained in performing percutaneous tracheostomy and that it should be used as the gold standard in elective tracheostomy insertion. In cases where difficulties are likely to be anticipated, percutaneous tracheostomy can still be considered as the first option. This can be performed in the operating theatre setting with the knowledge that if any complication should occur then conversion to surgical tracheostomy can be done without delay.

Guidelines, standards and protocols are now widespread in clinical oncology. Although based on randomized trial evidence where possible, most are based on professional consensus. However, the goal of incorporating patient and carer views meaningfully in such guidelines has proved elusive. We performed a qualitative, focus group study of patients with head and neck cancer, their carers and bereaved carers in the South and West of England. Patients and carers were asked to discuss their views on a series of professionally-derived standards for care. Pilot work showed that convening patient groups twice was more productive, allowing the first to discuss ‘the patient story/journey’ and the second to be more directed at specific standards, suitably translated into lay language. The results demonstrated that such methodology was applicable even to groups of patients traditionally viewed as ‘difficult’, such as laryngectomy patients, facially disfigured persons and bereaved carers. Participants were able to comment meaningfully on the standards and the process of head and neck cancer care as a whole. National (BAO-HNS) standards were modified with the results of the study. Focus groups, especially reconvened groups, are an effective way of gaining patient and carer views of professionally-derived standards in oncology. However, professional qualitative researcher help is required, and it is not necessarily ‘easy’ or cheap.

A case of rhinolithiasis in Southeast Botswana was treated and after removal in hospital, the rhinolith was subjected to macroscopic and microscopic examination, X-ray diffraction analysis, electron microscope analysis and partial botanical analysis.

The rhinolith consists of a strongly elliptical core of calcium stearate (C36H70CaO4.H2O), surrounded by approximately 30 elongated concentric growth rings, consisting of sodium-containing whitlockite (Ca18Mg2(Na,H)(PO4)14). The different layers have various degrees of porosity and red staining, probably due to traces of amorphous iron oxide. The origin of the rhinolith started with a piece of plant material, lodged in the nose, which was replaced by calcium stearate, leaving some remnants of resistant epidermal plant tissue. During subsequent years, thin layers of whitlockite were deposited periodically around the core with the reddish brown bands representingdeposition during the dry season when atmospheric dust rich in amorphous iron oxide is at its highest in Botswana.

It is common to see cholesterol granuloma in the mastoid air cells, less common in the orbit, and uncommon in the paranasal sinuses. Cholesterol granuloma is thought to be due to an interruption to normal aeration with impaired lymphatic drainage, resulting in a closed cavity where it may form. These expanding cysts cause bone destruction and compression of the surrounding structures that lead to clinical symptoms. Diagnosis and management of cholesterol granuloma cysts can be challenging. Magnetic resonance imaging (MRI) and computed tomographic (CT) scans are usually diagnostic. We present a rare case of cholesterol granuloma in the frontal sinus, few cases have been reported in the literature.

Malignant tumours of the nasal cavities and paranasal sinuses are uncommon.They constitute less than one per cent of all tumours and less than three per cent of head and neck tumours. Although multiple primary carcinomas of the aerodigestive tract are commonly reported, metachronous maxillary sinus carcinomas are rare. To date, all of these cases reported are of squamous cell origin. The incidence of metachronous maxillary carcinoma involving both sinuses is in the range of 1.4 per cent amongst patients with maxillary carcinoma. We present the first reported case, to our knowledge, of a patient with metachronous adenocarcinoma of the maxillary sinus.

Familial clustering of congenital bilateral abductor vocal fold paralysis has been reported very rarely. So far, only a handful of cases have been reported, mostly with the autosomal dominant of X-linked recessive mode of inheritance. We describe the cases of a brother and sister, who presented with neonatal stridor due to bilateral abductor vocal fold paralysis. First-degree parental consanguinity suggests an autosomal recessive mode of inheritance. Karyotype analysis revealed a paracentric balanced inversion of chromosome 13 in both cases, that was also present in the unaffected mother. An updated review of the literature on this interesting but rare condition is also presented.

A rare case of a tonsillar neurofibroma in a 28-year-old Caucasian male is presented. Benign tumours of the tonsils are rare and of those reported, only a few are benign peripheral nerve sheath tumours (BPNSTs). This is the first report of a solitary neurofibroma of the palatine tonsil in the English literature.

We report the case of a 75-year-old man who presented with an ischaemic tongue. He was known to have external carotid artery stenosis and a history of a transient ischaemic attack. He was treated with a heparin infusion and the tongue healed well.

In a patient presenting with haematemesis, known to have oesophageal varices, the bleeding would be expected to be from those varices. This case demonstrates an unusual presentation of a base of skull fracture; blood from a fracture of the temporal bone had run from the middle ear through the eustachian tube to the pharynx. It demonstrates the need to remainvigilant even when the diagnosis appears to be obvious.