This study aimed to develop a multidisciplinary coded dataset standard for nasal surgery and to assess its impact on data accuracy.

An audit of 528 patients undergoing septal and/or inferior turbinate surgery, rhinoplasty and/or septorhinoplasty, and nasal fracture surgery was undertaken.

A total of 200 septoplasties, 109 septorhinoplasties, 57 complex septorhinoplasties and 116 nasal fractures were analysed. There were 76 (14.4 per cent) changes to the primary diagnosis. Septorhinoplasties were the most commonly amended procedures. The overall audit-related income change for nasal surgery was £8.78 per patient. Use of a multidisciplinary coded dataset standard revealed that nasal diagnoses were under-coded; a significant proportion of patients received more precise diagnoses following the audit. There was also significant under-coding of both morbidities and revision surgery.

The multidisciplinary coded dataset standard approach can improve the accuracy of both data capture and information flow, and, thus, ultimately create a more reliable dataset for use outcomes and health planning.

When performing septoplasty or septorhinoplasty, we have observed that patients blink on injection of local anaesthetic (lidocaine 1 per cent with adrenaline 1:80 000) into the nasal mucosa of the anterior septum or vestibular skin, despite appropriate general anaesthesia. This study sought to quantify this phenomenon by conducting a prospective audit of all patients undergoing septoplasty or septorhinoplasty.

Patients were observed for a blink reflex at the time of local anaesthetic infiltration into the nasal vestibule. Also measured at this point were propofol target-controlled infusion levels, remifentanil rate, bispectral index, blood pressure, heart rate, pupil size and position, and patient movement.

There were 15 blink reflexes in the 30 patients observed. The average bispectral index value was 32.75 (range, 22–50) in the blink group and 26.77 (range, 18–49) in the non-blink group. No patients moved on local anaesthetic injection.

The blink reflex appears to occur in 50 per cent of patients, despite a deep level of anaesthesia. Without an understanding and appreciation of the blink reflex, this event may result in a request to deepen anaesthesia, but this is not necessary and surgery can proceed safely.

The endoscopic modified Lothrop procedure is mainly used for refractory frontal sinusitis. However, we have used it as an access procedure to facilitate treatment for an extended range of additional frontal sinus pathologies.

A retrospective review of patients who underwent the endoscopic modified Lothrop procedure for ‘alternative’ frontal sinus pathologies was conducted. Patient data were reviewed. The main outcome parameter measured was signs of recurrence.

Twelve patients (6 males, 6 females) from a 7-year study period, with a mean age of 45.2 years (range, 16–78 years), were analysed. The surgical indications included frontoethmoidal mucoceles, cerebrospinal fluid leaks within the frontal sinus, cystic fibrosis, frontal sinus osteoma, frontal sinus ossifying fibroma and frontal silent sinus syndrome. The mean follow-up period was 33.3 months. There were no known recurrences.

We have used the endoscopic modified Lothrop procedure for a range of frontal sinus pathologies, safely and effectively, with no peri-operative complications.

To demonstrate a novel and effective surgical technique for the treatment of refractory cerebrospinal fluid rhinorrhoea after skull base surgery. The novel surgical technique is described and the findings of a review of relevant world English-language publications are reported.

A 44-year-old woman, otherwise fit and well, presented with more than a 2-year history of right-sided facial pain. A diagnosis of classical trigeminal neuralgia was made. Surgical treatment was undertaken with a retromastoid suboccipital craniotomy. Post-operatively, the patient showed signs of right-sided cerebrospinal fluid rhinorrhoea which was recalcitrant. In light of a continuous leak and several hospital admissions, a novel technique was performed whereby the eustachian tube orifice was obliterated using an endonasal endoscopic approach. The technique proved to be successful, with no further leakage.

Endoscopic obliteration of the eustachian tube using a double seal technique is a simple, safe and effective procedure in the treatment of a refractory cerebrospinal fluid leak.

Scytalidium dimidiatum is a soil and plant pathogen that frequently affects fruit trees, but can also cause human infection. There are only two reported cases of invasive fungal sinusitis involving this rare micro-organism.

This paper reports the first case of invasive fungal sinusitis caused by Scytalidium dimidiatum occurring in a young immunocompetent patient from a non-endemic region, and discusses potential sources of exposure and relevance of local factors.

Case report.

The patient was treated successfully with a combination of functional endoscopic sinus surgery, and antifungal and corticosteroid treatment.

This paper describes the first reported case of invasive fungal sinusitis secondary to Scytalidium dimidiatum in a young immunocompetent patient from a non-endemic region. Importance is placed on following a systematic process of investigation and management, and adhering to well-defined basic surgical principles.

This case report describes the endoscopic transsphenoidal management of a cholesterol granuloma situated in a technically challenging part of the petrous apex, and the associated peri- and post-operative complications that arose. The literature on diagnosis and management of petrous apex cholesterol granulomas is reviewed.

Surgical intervention was attempted on three occasions, each time via an endoscopic, transsphenoidal approach with image guidance. The procedure was abandoned on the first occasion as there was a significant risk to the carotid artery; only a small drainage ostium was created because of the proximity of the carotid artery. The second attempt, complicated by copious bleeding from the clival venous plexus, was arrested prematurely. Successful drainage was achieved at the third attempt, but recovery was complicated by tension pneumocephalus.

The transnasal route is less invasive than a lateral labyrinthine or cochlear approach, and spares cochlear and vestibular function. However, this approach is not without risk. It is important to consider the natural anatomical variance of vasculature when planning surgical intervention for a lesion situated in a technically challenging part of the petrous apex. Additional magnetic resonance venography is recommended to circumnavigate the venous plexus, thereby avoiding an unexpected breach.

Craniofacial fibrous dysplasia commonly affects the larger mandible and the maxillary bones. Although involvement of the frontal, temporal and sphenoid bones has been described, fibrous dysplasia of the nasal bone has not been previously described; the two cases reported here have been made rarer by their isolated involvement. Clinical management is dependent on disease activity and patient symptoms.

To present two cases of isolated fibrous dysplasia of the nasal bone: a 46-year-old woman with gradual widening of the nasal bridge and a 47-year-old man with an incidental finding of a nasal bone mass.

Two case reports.

The 46-year-old woman underwent excision of the lesion while the 47-year-old man opted for watchful waiting.

We have presented the first case reports of fibrous dysplasia of the nasal bone. The care of these patients should be customised to their needs and wishes.

The management of frontal sinus disease in cystic fibrosis patients represents a challenge for many surgeons. Procedures can vary from the minimally invasive to those involving extensive open surgery.

This study describes the outcomes of the endoscopic modified Lothrop procedure, in terms of safety and morbidity, for cystic fibrosis patients with frontal sinus disease who did not improve following traditional functional endoscopic sinus surgery.

The study setting was a tertiary referral unit in a London teaching hospital, the largest national base for adult cystic fibrosis patients. Two patients diagnosed in childhood with cystic fibrosis presented with histories of recurrent, severe frontal sinusitis; both had previously undergone multiple endoscopic sinus surgical procedures. The modified Lothrop procedure was performed on both patients. The outcome measures were symptom resolution and post-operative complications.

The endoscopic modified Lothrop procedure was beneficial in the cystic fibrosis patients with frontal sinus disease who failed to respond to standard functional endoscopic sinus surgery procedures.

We report the use of triamcinolone injections to correct severe nasal deformity due to sarcoidosis, as an alternative to formal surgical rhinoplasty.

A 30-year-old woman with a long-standing history of sarcoidosis presented to a tertiary referral rhinology clinic complaining of breathing difficulty and nasal deformity. Flexible nasoendoscopy revealed red nasal plaques typical of nasal sarcoidosis, together with significant widening of the nasal bridge. Triamcinolone, a long-acting corticosteroid, was injected both intralesionally and subcutaneously over the nasal dorsum, at zero, three and eight months, resulting in long-lasting improvement of the nasal shape.

Sarcoidosis is a non-caseating, granulomatous, epithelioid inflammation. Otorhinolaryngological manifestations occur in approximately 10 per cent of patients; however, there is little published experience of nasal reconstruction in such patients. We describe a quick, simple and relatively cost-effective technique, with little or no co-morbidity, with which to improve the aesthetic and symptomatic outcomes of nasal sarcoidosis.

We present two cases of dental implant migration into the maxillary sinus, with subsequent removal via image-guided, transnasal endoscopy.

Presentation of clinical cases, together with a literature review of alternative surgical techniques, the theories behind implant migration, and the benefits of an image-guided, endoscopic approach.

One patient was asymptomatic, and the other had begun to experience sinogenic symptoms after implant displacement. Both patients presented to the ENT clinic, and both underwent the BrainLab protocol to generate computed tomography images for navigational reconstruction. Transnasal endoscopy was carried out with this guidance, and the implants were removed successfully in both cases. Previously used surgical techniques such as the Caldwell-Luc procedure or extraction through the tooth socket have higher rates of conversion to open procedures, more damage to the nasal sinuses and higher post-operative complication rates compared with the transnasal endoscopic approach.

Both patients underwent successful removal of their migrated dental implants with no complications, and neither required any follow-up intervention.

To describe a previously unreported case of repair of a lateral frontal sinus cerebrospinal fluid leak, using the endoscopic modified Lothrop procedure.

Case report of new technique, with reference to the world literature.

An effective endoscopic, transnasal repair of a lateral frontal sinus cerebrospinal fluid leak was achieved in a 60-year-old man. The defect was closed with fat, fascia lata and free mucosal grafts. The left nasal cavity was packed and a lumbar drain left in situ post-operatively. The drain and packs were removed one week later and the patient discharged with no complications, and no recurrence at 12 months' follow up.

Such cerebrospinal fluid leaks have traditionally been repaired using an external approach with osteoplastic flaps and obliteration of the sinus. We highlight the endoscopic modified Lothrop technique as an effective alternative approach to repair of cerebrospinal fluid leaks in poorly accessible areas of the frontal sinus.