It is well known that laryngeal squamous cell carcinoma is strongly related to tobacco and alcohol consumption. Accumulating evidence suggests that alterations of detoxification enzymes, such as glutathione S-transferases and N-acetyltransferases, influence the risk of cancers associated with tobacco smoke and alcohol.

This was a retrospective case–control study. The study group consisted of 88 Greek patients with laryngeal squamous cell carcinoma; there were also 102 control subjects. Frequencies of the genotypes GSTT1, GSTM1, GSTM3 and NAT2 were evaluated by polymerase chain reaction restriction fragment polymorphism.

The distribution of overall genotypes was 55.68 per cent rapid acetylator and 44.32 per cent slow acetylator in patients, and 36.27 per cent rapid acetylator and 63.72 per cent slow acetylator in controls. The odds ratio for rapid acetylator status in cases versus controls was 2.207 (95 per cent confidence interval 1.23–3.95, p = 0.0087).

This study demonstrated a significant relationship between rapid acetylator genotypes and laryngeal squamous cell carcinoma in a Greek population.

To demonstrate the clinical, radiological and diagnostic pitfalls of managing an isolated frontal sinus fungus ball, and to compare with the literature.

Retrospective analysis of two cases and literature review.

Isolated frontal sinus fungus ball is a rare cause of frontal sinus disease. We present two cases of isolated frontal sinus fungus ball which pre-operatively were suspected to be either a tumour or a mucocele. In both cases, cheesy, clay-like material was found intra-operatively within the frontal sinus, suggesting a fungus ball. Effective treatment included surgical debridement via an exclusively endoscopic or an external approach, variously. Final histopathological and mycological analysis revealed Aspergillus fumigatus. A literature review revealed 20 reported cases of isolated frontal sinus fungus ball, confirming the low prevalence of the disease.

Frontal sinus fungus ball should be considered in the differential diagnosis of chronic, nonspecific forehead symptoms. To evaluate the underlying disease, computed tomography scans should first be performed, followed by magnetic resonance imaging if malignancy is suspected. It is essential to be aware of the possibility of an atypical fungus ball appearance on computed tomography and magnetic resonance imaging scans. If bony destruction and calcification coexist on radiological images, then endoscopic biopsy is an indispensable part of the diagnostic procedure, and should be performed to collect material for both histological and mycological analysis, and to aid surgical planning. In cases of sinus fungus ball, an endoscopic approach for biopsy may be curative.

There is growing interest in the long term outcomes of critical care. The degree of vocal morbidity suffered by patients surviving intensive care admission has not previously been reported.

To determine the degree of subjective, patient-reported vocal morbidity following discharge from intensive care.

A prospective study was undertaken of patients admitted to intensive care. A total of 273 consecutive admissions were assessed; 181 patients were suitable for inclusion.

The Voice Symptom Scale questionnaire.

Eighty-three patients responded. Twenty-seven patients (33 per cent) reported a degree of vocal morbidity greater than that suffered by patients treated for early laryngeal cancer. Thirteen patients (16 per cent) reported a degree of morbidity greater than that suffered by patients attending voice clinics.

Up to one-third of patients who survived admission to an intensive care unit reported suffering significant vocal morbidity. The Voice Symptom Scale could be used in an intensive care follow-up setting to identify and ensure the referral of such patients.

To compare the efficacy and safety of radiofrequency and monopolar electrocautery tonsillectomy, regarding operation duration and tonsillectomy morbidity, including post-operative pain and haemorrhage and tonsillar fossa healing, in patients with recurrent chronic tonsillitis.

A prospective, randomised, double-blind, controlled clinical study.

Fifty patients aged over 10 years who required tonsillectomy were randomly assigned to have one tonsil removed by radiofrequency and the other by monopolar electrocautery. Operation duration, post-operative haemorrhage, post-operative pain and tonsillar fossa wound healing were compared.

The mean ± standard deviation of the operation duration required for the radiofrequency method was significantly longer than that for monopolar electrocautery: 8.1 ± 1.6 minutes vs 7.3 ± 1.5 minutes, respectively (p = 0.034). Post-operative haemorrhage was observed in only three patients (13.6 per cent). Inter-group analysis showed no significant differences in post-operative pain scores for the radiofrequency vs monopolar electrocautery methods (3.7 ± 1.6 vs 3.3 ± 1.4, respectively; p < 0.126). Inter-group analysis showed that tonsillar fossa wound healing scores evaluated on the fifth, 10th and 14th post-operative days were significantly higher in the radiofrequency group compared with the monopolar electrocautery group (p < 0.001).

The present study results indicated that monopolar electrocautery tonsillectomy was superior to radiofrequency tonsillectomy in terms of post-operative tonsillar fossa wound healing; however, both techniques were comparable in terms of post-operative pain.

This study aimed to clarify the local immune status in the larynx in the presence of infection or carcinogenesis associated with human papilloma virus.

Cytological samples (for human papilloma virus detection) and laryngeal secretions (for immunoglobulin assessment) were obtained from 31 patients with laryngeal disease, during microscopic laryngeal surgery. On histological examination, 12 patients had squamous cell carcinoma, four had laryngeal papilloma and 15 had other benign laryngeal disease. Cytological samples were tested for human papilloma virus DNA using the Hybrid Capture 2 assay.

High risk human papilloma virus DNA was detected in 25 per cent of patients (three of 12) with laryngeal cancer. Low risk human papilloma virus DNA was detected only in three laryngeal papilloma patients. The mean laryngeal secretion concentrations of immunoglobulins M, G and A and secretory immunoglobulin A in human papilloma virus DNA positive patients were more than twice those in human papilloma virus DNA negative patients. A statistically significant difference was observed between the secretory immunoglobulin A concentrations in the two groups. Patients with laryngeal cancer had higher laryngeal secretion concentrations of each immunoglobulin type, compared with patients with benign laryngeal disease. The study assessed the mean laryngeal secretion concentrations of each immunoglobulin type in the 12 laryngeal cancer patients, comparing human papilloma virus DNA positive patients (n = 3) and human papilloma virus DNA negative patients (n = 9); the mean concentrations of immunoglobulins M, G and A and secretory immunoglobulin A tended to be greater in human papilloma virus DNA positive cancer patients, compared with human papilloma virus DNA negative cancer patients.

These results suggest that the local laryngeal immune response is activated by infection or carcinogenesis due to human papilloma virus. The findings strongly suggest that secretory IgA has inhibitory activity against infection or carcinogenesis associated with human papilloma virus in the larynx.

We present the largest recorded case series of holmium:YAG laser use in otolaryngology. This laser's hand-held delivery device is easier to manipulate compared with other ENT lasers, and its pulsed delivery mode gives it enhanced cutting and coagulation properties.

We conducted a 12-year, retrospective study of holmium:YAG laser use in a tertiary referral centre. Sixty-eight patients were included. Nineteen received primary laser treatment of squamous cell carcinoma of the upper aerodigestive tract (nine with simultaneous neck dissection), and 49 underwent either palatine or lingual tonsillectomy for benign disease. One cancer patient developed a pharyngo-cutaneous fistula, and a second suffered a secondary haemorrhage. No other complications were recorded. There were no local recurrences.

The holmium:YAG laser is safe and effective for benign and malignant otolaryngological conditions. In cancer treatment, it may be best to delay neck dissection until the primary site has healed, in order to avoid fistula formation.

We report a rare case of a nasal glioma found incidentally in an adult, presenting with visual loss, optic nerve oedema and proptosis.

A 41-year-old woman presented with bilateral proptosis, impairment in visual acuity (6/60 bilaterally) and loss of colour vision. Computed tomography and magnetic resonance imaging showed proptosis, bilateral optic nerve swelling and a heterogeneous mass occupying the left nasal cavity and extending through a skull base defect into the anterior cranial fossa. Biopsy confirmed a nasal glioma. Treatment with intravenous dexamethasone resolved the proptosis, and the patient's visual acuity recovered to 6/9 bilaterally. At the multidisciplinary team meeting, it was felt that the nasal glioma probably represented an incidental finding and was not directly responsible for the patient's proptosis and transient visual loss.

To our knowledge, this is the first report in the English language literature of adult nasal glioma presenting with visual loss. The management of nasal gliomas in adults is contentious and the relevant literature is reviewed. This case was managed conservatively with regular follow up.

This study determined readability scores for sequential letters written to general practitioners and copied to patients, following ENT consultations at the Royal United Hospital in Bath. Intervention involved educating clinicians in techniques to improve readability.

A total of 295 letters from eight clinicians were assessed in the pre-intervention phase. The mean Flesch reading ease score was 61.8 (standard deviation 8.7) and the mean Flesch–Kincaid reading grade was 9.0 (standard deviation 1.7). Re-audit analysed a further 301 letters. There was no significant change in the readability of the letters post-intervention.

It may not be feasible to present medical information intended for general practitioners in a way that is readable to most of the UK adult population.

We report a rare case of mitochondrial neurogastrointestinal encephalomyopathy with hearing loss.

A 46-year-old woman presented with a three-year history of progressive, bilateral hearing loss and tinnitus. She had been suffering from unexplained abdominal pain and diarrhoea for 20 years. When first seen, her otoscopic findings were normal, and pure tone audiometry showed mild and moderate hearing loss in her right and left ears, respectively. She also had: bilateral ophthalmoparesis, neck and limb muscle weakness, and hypoactive deep tendon reflexes on neurological examination; diffuse leukoencephalopathy on magnetic resonance imaging of the brain; and markedly reduced leukocyte thymidine phosphorylase activity. On the basis of these findings, the patient was diagnosed with mitochondrial neurogastrointestinal encephalomyopathy.

Mitochondrial neurogastrointestinal encephalomyopathy is an autosomal recessive disease caused by mutation of the thymidine phosphorylase gene, and is characterised by ophthalmoparesis, peripheral neuropathy, leukoencephalopathy, gastrointestinal symptoms and abnormal mitochondria in muscle cells. Current advances in genetic research may reveal a higher prevalence of mitochondrial disorders than had previously been thought. Otolaryngologists should be aware of mitochondrial neurogastrointestinal encephalomyopathy and other rare genetic disorders when managing patients with progressive hearing loss.

To survey antibiotics prescribed for patients admitted with acute tonsillitis and peritonsillar abscess to UK ENT departments.

An anonymous postal questionnaire was sent to UK ENT consultants.

Intravenous benzylpenicillin alone was preferred significantly more often for acute tonsillitis (n = 175) than for peritonsillar abscess (83) (p < 0.001). A combination of benzylpenicillin and metronidazole was preferred significantly more often for peritonsillar abscess (n = 131) than for tonsillitis (62) (p < 0.001).

In this survey, penicillin was the commonest antibiotic choice for tonsillitis; this is in accordance with published guidelines. For cases of peritonsillar abscess, benzylpenicillin with metronidazole was the most common antibiotic combination chosen. However, the high resolution rate of peritonsillar abscess following drainage and treatment with penicillin alone suggests that multiple antibiotics are unnecessary and inappropriate in this setting.

To review early oncological outcomes following transoral CO2 laser resection of laryngeal and hypopharyngeal squamous cell carcinoma.

Retrospective review of hospital electronic database.

Large district general hospital in England, UK.

Patients' three-year disease-specific survival and disease-free survival were evaluated, including post-operative complications, voice quality and swallowing status.

Seventy-seven patients (16 women and 61 men) were identified. Transoral laser excision of squamous cell carcinoma of the larynx was undergone by 65 patients, and the same procedure in the hypopharynx by 12. Patients with laryngeal cancer had statistically better disease-specific survival than those with hypopharyngeal cancer (p = 0.021), although the cumulative disease-free survival probability was 0.71 for both larynx and hypopharynx groups. Patients who underwent laryngectomy following failed laser treatment or as a salvage procedure had poorer outcomes.

The overall results of this study were comparable with those of other, larger studies. At three-year follow up, cumulative disease-specific survival probabilities were 0.92 and 0.71 for laryngeal and hypopharyngeal squamous cell carcinoma, respectively.

To evaluate the peri-operative usefulness of dexmedetomidine in obstructive sleep apnoea surgery.

In a clinical audit, patients were divided into a study group (dexmedetomidine used; n = 125; 82.9 per cent males, 17.1 per cent females; mean age 48.1 years) and a control group (dexmedetomidine not used; n = 143; 85.5 per cent males, 14.5 per cent females; mean age 47.4 years). The selected outcome measures were mean arterial pressure, use of anti-hypertensives and use of opioids.

Mean arterial pressure was stable (i.e. below 100 mmHg) in 93.3 per cent of the study group and 72.0 per cent of the control group (relative risk 1.30, 95 per cent confidence interval 1.14–1.47). The use of glyceryl trinitrate and hydralazine was significantly less in the study group, compared with controls (p = 0.005 and <0.001, respectively). Study group patients underwent more procedures than control patients (p < 0.001) and were more likely to require morphine. No difference was noted in the median dose of opioids.

Dexmedetomidine improves haemodynamic stability in patients undergoing surgery for obstructive sleep apnoea. It is reliable and reduces the need for polypharmacy. Its opioid-sparing action has been established in the literature; however, this was not demonstrated in our study.

We report a rare and unusual case of a patient with an ingested fishbone which migrated from the oropharynx to the anterior compartment of the retropharyngeal space and then to the deep neck space in the nasopharynx (i.e. the carotid space). This report aims to describe a successful, minimally invasive method of foreign body removal which avoided both major skull base surgery and any potential life-threatening complications. A secondary aim is to highlight the role of intra-operative fluoroscopy, an under-used tool.

We present a 67-year-old man with a history of fish bone impaction but no fish bone visible on plain X-ray or flexible endoscopy. The diagnosis of fish bone lodged in the retropharyngeal space was confirmed by computed tomography. Surgical exploration of the anterior retropharyngeal space failed to locate the fish bone, as it had migrated to a new, unknown location. Intra-operative fluoroscopy was vital for the removal of the fish bone, as it was impossible to see with the naked eye and had migrated from its previously imaged position. The fish bone was finally retrieved bimanually using external pressure on the submandibular region, which displaced the fish bone, and fluoroscopic guidance, which assisted its removal from the nasopharyngeal lumen.

To the best of our knowledge, this is the first reported case of bimanual, intra-operative, fluoroscopy-guided, intra-luminal removal of a migratory fish bone from the deep neck space in this region of the nasopharynx.

A patients with undiagnosed type II diabetes mellitus presented with infective rhinocerebral mucormycosis.

Initial magnetic resonance imaging scans demonstrated an aggressive disease process involving the left orbit and paranasal sinuses. A repeated scan following treatment excluded intracranial spread or recurrence. Pus from the paranasal sinuses grew Rhizopus arrhizus on microbiological culture.

Initial treatment comprised intravenous liposomal amphotericin B, intravenous co-amoxiclav and surgical debridement. The patient's diabetes was managed medically. The development of drug-induced transaminitis required a change of medication. The dose of liposomal amphotericin B was reduced, and then titrated back up as the liver function test results improved. Posaconazole was also introduced and the patient was eventually discharged on this alone, as the maximum recommended cumulative dose of liposomal amphotericin B had been reached.

Posaconazole may be used effectively in conjunction with surgical debridement in the treatment of patients with infective rhinocerebral mucormycosis who develop hepatotoxic side effects to liposomal amphotericin B. Posaconazole may also allow a reduction in the dose of liposomal amphotericin B, resulting in better tolerance.

We report a case of a patient who presented with otalgia and facial nerve palsy secondary to an aspergilloma of the middle ear.

A 72-year-old, diabetic man presented to the ENT department with a history of worsening right-sided otalgia, aural discharge and hearing loss, associated with a right-sided facial weakness. This was assumed to be secondary to malignant otitis externa, and treatment was commenced. Imaging showed soft tissue within the middle ear and no bony erosion. Surgical exploration and biopsy revealed an aspergilloma of the middle ear. The pre- and post-operative management, as well as treatment strategies, are discussed.

To our knowledge, this is the first documented case of an aspergilloma of the middle ear with associated facial palsy. Readers are asked to consider this rare diagnosis in patients with suspected malignant otitis externa not responding to standard treatment.

The electroglottogram approximate entropy value is a numerical variable which gives an overall measure of voice quality. It is derived by analysing the complexity of the electroglottogram waveform using regulatory statistics.

(1) To use electroglottogram approximate entropy to measure voice quality in patients with glottic pathology and in normal subjects, to ascertain whether this parameter can distinguish between pathological and normal voices. (2) To ascertain whether electroglottogram approximate entropy can measure voice change over time within individual subjects. (3) To determine any correlation between electroglottogram approximate entropy and the grade–roughness–breathiness–asthenia–strain scale.

One hundred and forty-one normal volunteers were recruited to characterise electroglottogram approximate entropy in the normal voice. One hundred and eighty-six patients with glottic squamous cell carcinoma underwent electroglottogram approximate entropy measurement prior to radiotherapy and then three to six months and one year after treatment. Subjects’ voices were categorised by a speech therapist using the grade–roughness–breathiness–asthenia–strain scale.

The mean electroglottogram approximate entropy of the normal volunteers was 0.302 (range 0.05–0.42). The mean electroglottogram approximate entropy of the glottic squamous cell carcinoma patients was significantly lower prior to treatment, at 0.227 (range 0.001–0.397; p < 0.0005), but improved after radiotherapy to 0.277 at three to six months and 0.282 at one year. Electroglottogram approximate entropy results correlated significantly with grade–roughness–breathiness–asthenia–strain scale results.

Electroglottogram approximate entropy can be used to assess change in voice quality resulting from glottic morphological abnormality. Electroglottogram approximate entropy values improve as voice quality improves after treatment. Electroglottogram approximate entropy values correlate significantly with grade–roughness–breathiness–asthenia–strain scale results.

To assess elective surgery consent practices amongst senior house officers from a selection of UK ENT departments, and to compare results with similar surveys in 2002 and 2005.

A telephone survey of senior house officers in 40 UK ENT departments was conducted to assess departmental consent policies and knowledge of complications of common ENT operations.

A total of 77.5 per cent of responding senior house officers were responsible for consenting, reduced from 92.5 per cent in 2002 (p = 0.06). There had been a significant improvement in the use of patient information sheets, from 25 per cent of departments in 2002 to 65 per cent in 2008 (p = 0.0002). There had been no improvement in training or in the use of standard National Health Service consent forms, and the senior house officers' knowledge of specific complications remained poor. Of the senior house officers surveyed, 37.5 per cent were foundation trainees.

There has been some improvement in information delivery to patients during the consent process, in accordance with General Medical Council, Department of Health and Modernising Medical Careers guidelines. However, most senior house officers are still required to obtain patient consent without appropriate training.

To present a patient with a frontal sinus keratoma removed solely via endoscopic sinus surgery, including presentation of characteristic computed tomography and magnetic resonance images; to discuss the differential diagnosis of this condition; and to report the current knowledge on and treatment of frontal sinus keratoma.

A 53-year-old man presented to our department with a 10-month history of rhinorrhoea and postnasal drip. After computed tomography and magnetic resonance imaging studies, the patient underwent surgery utilising a modified Lothrop procedure. An extensive soft tissue lesion was removed from the frontal sinus. Histological examination revealed a lamellated cluster of keratinous material. The pathological diagnosis was keratoma of the frontal sinus. There was no recurrence of keratoma over a two-year follow-up period.

Following review of the English language literature, we believe this case report to represent the first successful application of a modified endoscopic Lothrop procedure for resection of an extensive frontal sinus keratoma. Thus, the applications of endoscopic sinus surgery may be expanded to include frontal sinus keratoma removal.