We report on three cases of patients whose primary symptoms of myasthenia gravis were related to the upper aerodigestive tract. Symptoms had been present unrecognized in all patients for up to three years, and one patient subsequently developed a myasthenic crisis. We highlight the clinical features of myasthenia gravis to allow its prompt recognition in patients presenting to the ENT surgeon or physician.

The clinical management and long-term outcome in lightning survivors with subsctantial ear damage treated at the Department of Otorhinolaryngology, University Hospital Split during the 1984–1999 period are reviewed. Results of clinical management and outcomes of lightning ear damage in 18 patients (mean age 35.3 ± 5 years) were retrospectively analyzed. On admission, all patients complained of severe pain, tinnitus and hearing impairment. Otomicroscopy revealed tympanic membrane rupture in 12 patients. The active therapeutic approach included immediate otomicroscopy, aseptic aspiration toilet, and eversion of perforation edges. In all patients, the ruptures healed well, and restitution of the hearing function was achieved. Follow-up examination performed in 1999 (13.2 ± 2.9 years later) in 11 patients (mean age 52.3 ± 6.1 years) revealed an almost identical audiogram as on discharge from the hospital, however, neuropsychological testing revealed numerous sequelae. Tympanic injury caused by lightning should be actively treated. Lightning survivors require additional psychotherapeutic treatment.

The arcuate eminence (AE) was studied in 21 Caucasian cadavers (42 temporal bones), with particular reference to its relationship to the superior semicircular canal (SSC) and the temporal lobe. An arc-like eminence was observed in over 80 per cent of specimens, however, they did not exactly correspond to the SSC and such eminences corresponded to the sulci of the temporal lobe. The round and domed eminence corresponded to each SSC in seven temporal bones. The distances between the SSC and the middle cranial fossa were varied (0–2.5 mm, mean: 1.2 mm+± 0.6 mm) whereas distances between the lateral semicircular canal and tympanic cavity were relatively consistent (0.6–1.4 mm, mean: 1.0 mm ± 0.2 mm).

These data indicate that the AE is trace of the temporal lobe and the SSC gave little effect to the surface of the middle cranial fossa. These findings could well be applicable to all humans.

High resolution T2-weighted magnetic resonance (MR) imaging has been proposed as a rapid, inexpensive means of investigating patients with sensorineural deafness, particularly to exclude vestibular schwannomas. Whether the accepted ‘gold standard’ of contrast-enhanced T1-weighted images can be omitted, however, remains controversial. Over a 22-month period the use of axial turbo-spin echo T2-weighted images (T2W) were prospectively compared with contrast-enhanced T1-weighted spin echo scans in the evaluation of 513 patients presenting with audiovestibular symptoms. A 2-D T2W turbo spin echo (TSE) sequence with 3 mm slices was used in 340 patients while a 3-D sequence with overlapping 1 mm slices was used in 173 patients. The T2-weighted image findings were documented and subsequently compared with contrast-enhanced images. With the 2-D sequence 24 patients (25 lesions) had internal auditory meatus (IAM)/cerebello-pontine angle (CPA) masses identified by contrast-enhanced T1-weighted images, all of which were seen on the T2-weighted TSE sequence; there was one false positive ‘mass’ on the T2-weighted scans and one false negative case of IAM dural enhancement on T1-weighted imaging; six were considered normal initially on the T2-weighted images although three were subtly abnormal in retrospect. With the 3-D sequence three acoustic neuromas were all identified correctly with no false positive and only one false negative result (labyrinthitis). The 2-D and 3-D images were judged technically inadequate for clinical assessment in 15 and nine per cent respectively. We conclude that mass lesions of the IAM/CPA can be reliably identified on T2W TSE imaging but labyrinthine lesions may be missed without contrast enhancement. This is of particular importance in planning the management of neurofibromatosis type 2. Non-neoplastic disorders of the inner ear are also likely to be missed.

The surgical closure of a nasal septal perforation is recognized as being particularly challenging. A series of 11 consecutive patients who underwent closure of a septal perforation using a mucosal flap/composite conchal cartilage graft technique are reviewed, and the surgical technique described. The size of the perforation repaired varied, with eight cases being 2 cm or more in diameter. There was no significant graft donor site morbidity and complete perforation closure was achieved in eight cases after a mean observation time of 19.8 months. These results suggest that this is a suitable technique for closing nasal septal perforation.

The management of chronic sino-nasal disease has changed significantly in the last 15 years with the advent of topical nasal steroids and minimally invasive endoscopic surgery, but survey data from district hospitals in the UK have not been published to date. We examined the current management of 383 consecutively scanned patients with sino-nasal symptoms in three district hospitals. Survey standards were set, and were attained in 56 per cent for symptom recording, 60 per cent for pre-scan diagnosis, 62 per cent for endoscopic examination in out-patients, and 73 per cent for topical steroid use before scanning. The variability of sinus disease makes it difficult to be dogmatic about proper indications for surgery, but subsequent surgical management, as ascertained from the notes, showed large differences between consultants in the three hospitals. The rate of minor complications was 2.2 per cent, there were no major complications, and the vast majority of patients stated that their nasal symptoms were improved by surgery. The survey showed that endoscopic sinus surgery is safe and effective when practised in a district hospital setting.

We reviewed 80 patients admitted to our hospital who were diagnosed with acute epiglottitis between January 1995 and March 1999, and their clinical features, evolution and treatments were analysed. No sexual predominance was found, and there was no patient younger than 16 years of age. The patient fatality rate was 1.3 per cent, and the hospitalization period was markedly longer than those of other reports.

A retrospective review of the notes of 100 consecutive patients who had undergone aryepiglottoplasty for laryngomalacia, at Great Ormond Street Hospital for Children, was undertaken. Fifty-six were male, 44 female and 47 were under three months of age. Indications for surgery were oxygen desaturation below 92 per cent and feeding difficulties causing failure to thrive. Forty-seven patients had other pathology contributing to their airway compromise or feeding problems. Improvement in stridor after one month was achieved in 86/91 (94.5 per cent) being abolished completely in 50/91 (55 per cent). Of the 25 per cent of patients whose symptoms took more than one week to resolve, 16/22 (63.6 per cent) were later found to have a serious neurological condition. Feeding was improved in 42 of 58 patients (72.4 per cent) who had a pre-operative feeding difficulty. The complication rate was low, with only five out of 86 (10 per cent) experiencing initial worsening of the airway and six per cent having aspiration of early feeds before improvement occurred.

Endoscopic aryepiglottoplasty remains the operation of choice for patients with severe laryngomalacia, however, in the presence of neurological disease surgery is less likely to be successful.

The feasibility of paediatric day-case tonsillectomy (PDCT) depends on its safety and acceptance by parents and patients. The purpose of our retrospective study of paediatric day-case tonsillectomy was to review the role of the home care team (HCT) in improving the safety and acceptance of the procedure.

Between January 1997 and June 1999, 352 consecutive children underwent day-case tonsillectomy. The notes and HCT assessment sheets were reviewed for telephone calls made by HCT or by parents, home visit by HCT, types of complication and their outcome.

The primary haemorrhage rate was 0.6 per cent. The effective day-case rate was 97 per cent. The unplanned admission rate was three per cent. The HCT visited about 25 per cent of patients at home. We conclude that paediatric day-case tonsillectomy is associated with high morbidity and considerable parental anxiety that can be dealt with by timely reassurance, support and advice by a dedicated HCT.

We report the use of a self-retaining aural speculum that provides an excellent view of the middle ear through a small endural incision. We have found this instrument of value in tympanoplasty and stapes surgery in particular.

Wegener’s granulomatosis is a systemic disease characterized by a granulomatous lesion that can affect any organ throughout the body.

This case-report illustrates the problem posed by a patient presenting with bilateral serous otitis media with marked sensorineural hearing loss, facial nerve paralysis and an atypical serological picture. The importance of early diagnosis and the protocol for the management of a patient with an uncertain diagnosis is discussed. Due to atypical presentations, only a high index of suspicion will ensure an early diagnosis.

A case is presented of an entirely intracanalicular meningioma in a 48-year-old woman that was excised via a conventional translabyrinthine approach to the internal auditory canal (IAC). Pre-operative magnetic resonance imaging (MRI) suggested that the tumour was a vestibular schwannoma (VS). Histological examination confirmed the intra-operative impression that the tumour was a meningioma. Although VS is by far the commonest intracanalicular tumour, the differential diagnosis includes meningioma. MRI is unable to distinguish between these two entities when the tumour is located entirely in the internal auditory canal.

The authors present a rare clinical entity in a schwannoma of the chorda tympani. The case is discussed including the difficulty in making the diagnosis and management.

We present a case of a seven-year-old child with a congenital facial palsy, diagnosed at birth, who subsequently developed a non-tuberculous mycobacterial (NTM) infection of the ipsilateral parotid gland. This required parotid exploration to treat the NTM disease with the intention of identifying and protecting the facial nerve to preserve any residual facial nerve function. At operation, thorough exploration revealed the complete absence of the nerve both at the stylomastoid foramen and more peripherally within the substance of the parotid gland. Exploration of the facial nerve for congenital facial paralysis is not normally indicated. Surgical treatment, if required, tends to involve the use of techniques such as cross facial nerve and free vascularized muscle grafting. To our knowledge this is the first reported case of complete congenital facial nerve agenesis, diagnosed incidentally during a surgical procedure for an unrelated condition.

Primary amyloidosis localized to the sinonasal tract is extremely rare with only 20 reported cases in the English literature. We describe a further case and review the literature.

Oncocytomas are rare tumours that occur predominantly in the major salivary glands, particularly the parotid of older individuals. We present the exceptionally rare occurrence of an oncocytoma in the post-nasal space and its treatment for the first time via a Le Fort I osteotomy. The potential for local spread to the surrounding skull base makes it vital to achieve good oncological clearance. We found that this was possible using the Le Fort I technique and would recommend that this approach should be considered in future, when approaching such lesions.

Puberphonia is predominantly a male condition which, normally affecting teenagers, may present in later life. It is defined as the failure to change from the high-pitched voice of the pre-adolescence to the lower pitched voice of adulthood. Patient previously reported have responded to voice therapy alone. We report the first surgically corrected case.

We report a case of sensory deprivation that occurred as a consequence of progressive head and neck lymphoedema, following combined surgery and radiotherapy for squamous cell carcinoma. The management of head and neck lymphoedema is discussed and measures are suggested for improving the sensory deprivation experienced by the worst affected patients.

In this case report, we present a solitary metastasis of renal cell carcinoma inside the masseter muscle. To our knowledge, it is the very first case ever encountered.

The masseteric space is an important tissue compartment of the neck, but disease in it is difficult to diagnose and treat. In this paper a case of a young adult male with an abscess of the submasseteric space is presented. Diagnosis was established by computed tomography (CT) of the neck, but the severity of the lesion was not accurately estimated. Surgical intervention was performed and a large quantity of pus was drained. A detailed medical history and clinical examination of the patient as well as CT are important tools in the accurate diagnosis and efficient treatment of the disease.