Hyaluronic acid has been proposed as a lubricant for improving the outcome of cochlear implant surgery. We describe a method which includes coating the electrodes with a thin layer of hyaluronic acid as well as using a droplet of the lubricant on the cochleostomy to provide additional magnification, like a lens, that facilitates the insertion of the electrode array. The use of hyaluronic acid reduces trauma to the cochlea and avoids contaminating perilymph by blood or by saline used during the operation. It is an efficacious and reliable method for cochlear implant surgery.

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.

Sudden sensorineural hearing loss that presents as the initial sign of haematological disease is very rare. Chronic myelogenous leukaemia has been implicated as a causative factor of sudden sensorineural hearing loss.

A 49-year-old male presented with unilateral sudden sensorineural hearing loss. The patient was found to have chronic myelogenous leukaemia during a work-up for his hearing loss. We present a case of a chronic myelogenous leukaemia patient whose first manifestation was sudden sensorineural hearing loss. We presume that cochlear vessel occlusion as a result of elevated blood viscosity was responsible for this patient’s hearing loss. Early onset of sudden deafness in a chronic myelogenous leukaemia patient may be due to the hyperviscosity syndrome and it may be possible to reverse hearing loss through early leukapheresis.

Between 1985 and 1999, 43 patients with locally-advanced, resectable oropharyngeal cancer were treated with combined surgery and post-operative radiation therapy (RT) at Oregon Health and Science University. Five patients (12 per cent) had Stage III disease and 38 patients (88 per cent) had Stage IV disease. All patients had gross total resections of the primary tumour. Thirty-seven patients had neck dissections for regional disease. RT consisted of a mean tumour-bed dose of 63.0 Gy delivered in 1.8–2.0 Gy fractions over a mean of 49 days. At three- and five-years, the actuarial local control was 96 per cent and the actuarial local/regional control was 80 per cent. The three- and five-year actuarial rates of distant metastases were 41 per cent and 46 per cent, respectively. The actuarial overall survival at three- and five-years was 41 per cent and 34 per cent, respectively. The actuarial rates of progression-free survival were 49 per cent at three-years and 45 per cent at five years. Combined surgery and post-operative RT for advanced-stage oropharyngeal cancer results in excellent local/regional control. This particular group of patients experienced a high-rate of developing distant metastases.

The association of Kallmann’s syndrome with conductive hearing loss has not previously been described. We report the findings at tympanotomy in three ears of patients with Kallmann’s syndrome and conductive deafness. The literature related to this topic is reviewed, and the treatment of these patients is discussed.

Treatment of auricular arteriovenous fistula (AVF) is a challenge with surgery being the preferred option until now. We present three cases of auricular AVFs who underwent pre-operative embolization and its outcome on surgery. Three patients were diagnosed to have auricular AVF by angiography. All three patients underwent pre-operative embolization with n-butyl 2-cyanoacrylate after which they underwent surgical resection of the AVF. Pre-operative embolization resulted in significant devascularization of the AVF thus leading to near bloodless and clean surgery. Pre-operative embolization of auricular AVFs is a good treatment option, leading to significantly reduced blood loss during surgical excision.

The objective of this presentation is to outline long-term complications and their management in contrast to acute measures after endotracheal laser-induced fire. This case focuses on a 56-year-old patient in whom an endotracheal fire occurred during CO2 laser surgery. Despite local swelling and evidence of acute lung injury, the patient was extubated the following day under single-shot cortisone and inhalation of dispersed adrenaline under assisted spontaneous breathing. Wound healing was assessed by regular flexible bronchoscopy and spirometry. Fourteen weeks after uneventful recovery, the patient presented with acute inspiratory stridor, related to a tracheal stenosis 2.5 cm distal to the glottic level. After tracheal end-to-end anastomosis, further follow-up was uneventful. Early extubation under ITU conditions avoided the need for tracheostomy and its sequelae. However, tracheal stenosis did not become apparent before week 14. While in acute management of laser-induced endotracheal fire a conservative approach was established successfully, the risk of further long-term complications implies the need for a prolonged follow-up regime even in cases of less extensive burns.

We present the results of a confidential telephone survey of ENT units in England on the disinfection of flexible fibre-optic nasendoscopes out-of-hours. The on-call residents of 124 units were contacted and questioned. In 35.1 per cent of units surveyed, the on-call resident was primarily responsible for cleaning the scopes after use. Only 46 per cent of these junior doctors had access to a chemical sterilant to allow for high-level disinfection of these scopes. Provision for disinfection of scopes was poorer in teaching hospitals and in units that served inner city populations. Only 12.1 per cent of Senior House Officers (SHOs) received any training in disinfection techniques and only 25.5 per cent of units kept a register of patients nasendoscoped out-of-hours for purposes of contact tracing.

Moderate to severe obstructive sleep apnoea is usually associated with multiple levels of pharyngeal airway collapse, including tongue base obstruction. A new technique has recently been introduced that improves the nocturnal retro-lingual airway. This study was a prospective, non-randomized single-institution evaluation of a recently introduced surgical technique. Nineteen consecutive patients with previously untreated moderate to severe obstructive sleep apnoea underwent tongue suspension using the Respose™ system and concomitant palatopharyngoplasty (multilevel pharyngeal surgery). The patient demographics and treatment outcomes were prospectively collected and retrospectively analysed.

There were 16 men and three women, with a mean (±SD) age of 44.9 years (±14.2) and a mean pre-operative apnoea-hypopnoea index (AHI) of 42.8 ± 24.8. Twelve of the 19 patients (63.2 per cent) have had post-operative polysomnography; eight of these 12 (67 per cent) met the standard criteria for surgical response. Among these eight patients, the AHI improved from 32.4 to 14.4 (p < 0.01); the individual scores fell by a mean of 51.7 per cent. The apnoea index improved from 7.4 to 0.9 (p < 0.01), with the individual scores falling by a mean of 81.4 per cent. There was anatomic and radiographic evidence of multilevel upper airway enlargement. Notably, the body mass index remained essentially unchanged (31.5 ± 7.2 to 31.2 ± 7.6, p > 0.5). Subjectively, the mean Epworth sleepiness scale score fell from 11.0 ± 5.4 to 5.4 ± 3.8 (p < 0.005). Four patients suffered transient velopharyngeal insufficiency, and two patients complained of limited anterior excursion of the tongue. There were no serious, long-term complications.

The tongue suspension procedure represents a minimally invasive technique for improving the nocturnal retro-lingual airway in patients with obstructive sleep apnoea. It is easily performed by otolaryngologists, distinguishing it from other established techniques designed to address tongue base obstruction.

The objective of this study was to assess patency of the internal jugular vein following modified radical or selective neck dissection and microvascular flap reconstruction by power Doppler ultrasound and its impact on free flap survival. In 23 patients who underwent selective or modified radical neck dissection and microvascular flap reconstruction the patency of the internal jugular vein was examined by power Doppler ultrasound on the first post-operative day and after follow-up of at least four months. On the first post-operative day in one patient partial thrombosis was found, while in the other 22 patients the internal jugular vein was normal patent. During follow-up in 17 (74 per cent) patients a normal patent internal jugular vein was found, while partial and complete thrombosis were found in three (13 per cent) patients each. On the first post-operative day 22 of the 23 (96 per cent) free flap veins were visualized. There was no free flap loss during follow-up. Power Doppler ultrasound is a valuable diagnostic technique for determination of internal jugular vein patency and may be useful as screening method or in case of clinical suspicion of thrombosis to determine internal jugular vein patency. Late internal jugular vein thrombosis may probably not effect free flap survival due to neovascularization.

We report the use of a nasal septal clip. We believe that this instrument is more easily inserted and removed when compared with the classical nasal packs.

Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the indication for tonsillectomy in the management of sore throat were published in January 1999. To determine adherence to these guidelines in our unit, clinical records were examined on admission for tonsillectomy. Three cohorts were analysed. The first listed prior to SIGN, the second after SIGN and the third after presentation of the results of cohorts 1 and 2. The records were examined for documentation of the number of attacks of tonsillitis in the preceding year. The first cohort revealed poor documentation of attacks of tonsillitis (30 per cent). Thesubsequent cohorts showed progressive improvement in record keeping (74 per cent and 96 per cent). The adherence to SIGN guidelines for those with adequate documentation also improved (75 per cent, 80 per cent, 93.5 per cent). The importance of adequate record keeping to enable audit of practice and the impact of national guidelines on practice are discussed.

We describe a rare case of a gradually progressive hearing loss in a patient with maternally inherited diabetes and deafness (MIDD) syndrome successfully rehabilitated with a cochlear implant. The possible aetiology of the hearing loss in these cases is discussed.

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.

Lemierre’s syndrome comprises internal jugular vein thrombosis following oropharyngeal sepsis and is a rare and serious condition. It is most commonly caused by the anaerobe Fusobacterium necrophorum and typically presents as metastatic sepsis to the lungs and joints. Thrombosis is demonstrated by computed tomography (CT) of the neck, and it is routinely treated with intravenous antibiotics and anti-coagulation.

We describe a case of Lemierre’s syndrome following acute supraglottitis. The clinical features were of retrograde intracranial thrombosis, rather than the more usual metastatic sepsis.

In cases of thyroid surgery that require a drain post-operatively, the authors suggest the subcutaneous tunnelling of the drain to exit in the bra-strap line. This simple but effective technique hides the potentially unsightly resultant scars that may be of concern to women wearing clothes that expose the upper chest and lower neck. The bra-strap line can be easily found in the patient and the authors have found no additional complications with exiting the drain at this site.

Epistaxis associated with hereditary haemorrhagic telangiectasia (HHT) is a challenging condition. Septodermoplasty, electrocautery and laser treatment often provide short-term relief only. The surgical closure of the nostrils (‘Young’s procedure’) represents a longer term solution but has the disadvantage of causing permanent complete nasal obstruction. A Silastic™ obturator has the advantage of being a non-surgical intervention and allows temporary relief of the nasal obstruction. We present the cases of three patients with HHT who used the obturator with good clinical effect, suggesting that this is a realistic non-surgical alternative to Young’s procedure for patients with HHT.

Tracheocutaneous fistula is a frequent sequel of long-term tracheostomy or tracheal fenestration. Closure of fistula is complicated by the presence of extensive scar tissue, mucopurulent secretions, and tension from insufficient advancement of adjacent soft tissue. We report two successfully closed cases of large tracheocutaneous fistulae using a hinge flap and a V-Y advancement flap.

Most cases of epistaxis are due to simple causes and are easily treated on an out-patient basis. However, there are some cases where the origin of bleeding is not obvious or arises from an unusual pathological source. The authors describe a case of epistaxis due to a mass in the maxillary antrum that when biopsied showed the histological appearances of a haemophilic pseudotumour. The patient was anticoagulated on warfarin for a cardiac valve replacement and this was thought to be the cause of the ongoing haemorrhage necessary for development of the pseudotumour. Even in haemophiliacs, pseudotumours are rare and we believe this case is unique in that the patient is a non-haemophiliac. The epistaxis was eventually controlled by external beam radiotherapy to the pseudotumour. The management of this case is outlined as well as a review of the literature on haemophilic pseudotumour.

Adult presentation of the Dandy-Walker syndrome is extremely rare. We report a case where the patient was first diagnosed at 75 years of age because of sudden onset of unilateral senorineural deafness and episodic vertigo. He remained well for a further three years until developing the more classical adult presenting features of cognitive impairment, disordered gait and ataxia. The radiological and otological investigative findings are discussed, together with their implications.