To provide an update on the ever-increasing role that embolisation plays in the practice of otolaryngology.

A literature search was performed during November 2008. The Medline, Embase, PubMed and Cochrane databases were searched. This resulted in 285 papers relevant for review.

The role of embolisation has expanded greatly to include the management of refractory epistaxis, pre-operative preparation of vascular tumours, vascular injuries and as an adjunct in skull base surgery.

To determine whether procedure-specific brochures improve patients' pre-operative knowledge, to determine the amount of information expected by patients during the consenting process, and to determine whether the recently proposed ‘Request for Treatment’ consenting process is viable on a large scale.

A prospective, questionnaire-based study of 100 patients admitted for selected, elective surgical procedures.

In total, 99 per cent of patients were satisfied with the information received in the out-patient department, regarding the proposed procedure. However, 38 per cent were unable to correctly state the nature of the surgery or specific procedure they were scheduled to undergo. Although the vast majority of patients were able to state the intended benefits to be gained from the procedure, only 54 per cent were able to list at least one potential complication, and 80 per cent indicated that they wished to be informed about all potential complications, even if these occurred in less than 1 per cent of cases.

The introduction of procedure-specific brochures improved patients' pre-operative knowledge. Although the failings of current consenting practice are clear, the Request for Treatment consenting process would not appear to be a viable alternative because of the large number of patients unable to accurately recall the nature of the proposed surgery or potential complications, following consent counselling.

(1) To assess hypersensitivity to bismuth iodoform paraffin paste impregnated ribbon gauze following its use in packing canal wall down mastoidectomy cavities; (2) to determine if isolation of the skin and mucosa from the pack, using thin Silastic sheeting and Cortisporin ointment, reduces hypersensitivity reactions, compared with a previous series; and (3) to review the literature and to determine if bismuth iodoform paraffin paste hypersensitivity precludes the consumption of seafood (due to its high iodine content).

All patients undergoing canal wall down mastoidectomy with intra-operative bismuth iodoform paraffin paste packing between 1985 and 2009 were identified and reviewed.

Of 587 patients identified, the overall bismuth iodoform paraffin paste reaction rate was 1 per cent. All reactions were in patients undergoing revision mastoidectomy procedures, giving a reaction rate for revision procedures of 2.4 per cent.

Reactions are an uncommon event following post-operative mastoid cavity packing using bismuth iodoform paraffin paste. Reaction rates may be lowered by preparing the cavity with Silastic sheeting and Cortisporin ointment prior to packing, thus isolating the skin and mucosal surfaces. Development of such a reaction does not preclude the consumption of seafood.

The temporal bone may be the first involved site in cases of systemic disease, and may even present with acute, mastoiditis-like symptomatology. This study aimed to evaluate the incidence of such non-infectious ‘acute mastoiditis’ in children.

Retrospective chart review of 73 children admitted to a tertiary referral centre for acute mastoiditis.

In 71 cases (97.3 per cent), an infectious basis was identified. In the majority of cases (33 of 73; 45 per cent), the responsible bacteria was Streptococcus pneumoniae. However, histopathological studies revealed a non-infectious underlying disease (myelocytic leukaemia or Langerhans' cell histiocytosis) in two atypical cases (2.7 per cent).

‘Acute mastoiditis’ of non-infectious aetiology is a rare but real threat for children, and a challenging diagnosis for otologists. A non-infectious basis should be suspected in every atypical, persistent or recurrent case of acute mastoiditis.

To evaluate the effect of different lipid fractions on auditory brainstem evoked responses in hyperlipidaemia.

We conducted a single institution (medical college), prospective, cross-sectional study of 25 hyperlipidaemic patients and 25 normolipidaemic controls, all with a normal hearing threshold on pure tone audiometry. Brainstem evoked response audiometry results were recorded in both groups. The hyperlipidaemic group were further divided into two subgroups, based on the serum value of each lipid fraction: those with less than and those with greater than the mean serum value. These two subgroups were further compared with the control group.

The hyperlipidaemic and normolipidaemic groups had statistically significant differences for all audiometry waves apart from the wave I and the III–V interpeak latencies. The subgroups had a statistically significant difference in brainstem evoked responses. We found a statistically significant association between low-density lipoproteins and many waveforms in the hyperlipidaemic group.

We found that low-density lipoproteins were significantly associated with many waveforms in hyperlipidaemic patients. Thus, low-density lipoproteins may be important in auditory dysfunction.

There is wide variation in UK prescribing practice regarding prophylactic antibiotics for nasal packing in spontaneous epistaxis. There are few published cases of infective complications in such patients.

This prospective study examined 149 consecutive patients admitted to a tertiary otorhinolaryngology centre with spontaneous epistaxis, who underwent nasal packing, over a six-month period. In the first three-month period, 78 patients were routinely prescribed prophylactic antibiotics; in the second three months, 71 patients were not routinely prescribed antibiotics. Exclusion criteria included antibiotics prescribed for unrelated pathology and post-operative epistaxis. Signs and symptoms of acute otitis media, sinusitis and toxic shock syndrome were assessed using clinical examination and a questionnaire.

Fourteen of the 149 patients experienced otalgia, most commonly following posterior nasal packing. No patient in either group had evidence of any infective complication.

We do not recommend the routine prescription of prophylactic antibiotics for patients undergoing nasal packing for spontaneous epistaxis.

This study aimed to analyse demographic profiles and pre-injection stroboscopic findings for patients with unilateral vocal fold paralysis, to investigate possible predictive factors for voice outcomes of injection laryngoplasty.

Fifty-nine unilateral vocal fold paralysis patients underwent vocal fold augmentation, using transcutaneous Artecoll (polymethyl methacrylate microspheres plus bovine collagen) injection into the paralysed vocal fold via the cricothyroid space. Three months later, patients were divided into improved (n = 44) and unimproved (n = 15) groups, using the perceptual grade-roughness-breathiness-asthenia-strain scale, and their clinical characteristics and pre-operative stroboscopic findings compared.

The improved group were significantly younger than the unimproved group (p = 0.000). The size of the posterior gap on phonation was closely associated with the outcome of injection laryngoplasty (p = 0.015).

Younger patients with a smaller posterior glottic gap on phonation can be expected to have a more favourable outcome following injection laryngoplasty for correction of glottic insufficiency due to unilateral vocal fold paralysis.

To demonstrate that patients who have been intubated for prolonged periods of time will have an increased likelihood of developing bacterial biofilm on their endotracheal tubes.

We collected endotracheal tubes from patients at the time of extubation, and analysed representative sections with scanning electron microscopy for morphologic evidence of biofilms.

From September 2007 to September 2008, 32 endotracheal tubes were analysed with electron microscopy. Patients who had been intubated for 6 days or longer had a significantly higher percentage of endotracheal tubes that exhibited bacterial biofilms, compared with patients intubated for less than 6 days (88.9 versus 57.1 per cent, p = 0.0439).

Longer duration of intubation is associated with a higher incidence of bacterial biofilm. Further research is needed to link the presence of bacterial biofilms to acquired laryngotracheal damage.

Limited information is available on mucosa-associated lymphoid tissue lymphomas arising in the head and neck.

A retrospective analysis was conducted of 20 patients who were histologically diagnosed with mucosa-associated lymphoid tissue lymphoma and treated at our institution between January 1990 and December 2009.

Treatment consisted of surgical resection alone in two patients (10 per cent), surgical resection with consecutive radiotherapy in one (5 per cent), and radiotherapy alone in eight (40 per cent). Three patients (15 per cent) were treated with systemic chemotherapy, and three (15 per cent) received chemoradiotherapy. Three patients (15 per cent) were informed of the diagnosis but not treated for their condition.

All of the 20 patients were still alive after a mean follow-up period of 50.8 months. Local treatment for mucosa-associated lymphoid tissue lymphoma of the head and neck should be the first choice in early-stage disease. However, prolonged follow up is important to determine these patients' long-term response to treatment.

Most human immunodeficiency virus positive patients now have a longer life expectancy, with the advent of highly active antiretroviral therapy. However, they are now at increased risk of developing a malignancy during their lives.

To investigate the age at which oral squamous cell carcinoma presents in patients infected with human immunodeficiency virus.

Prospective, clinicohistopathological audit of patients infected with human immunodeficiency virus.

Of 200 human immunodeficiency virus positive patients, 16 (8 per cent) presented with oral squamous cell carcinoma (nine women and seven men; age range 18–43 years, mean age 31.7 years). The majority of patients (62.5 per cent) had stage III and IV disease (tumour-node-metastasis staging). There was a predilection for poorly differentiated oral squamous cell carcinoma (using Broder's histopathological classification).

Oral squamous cell carcinoma associated with human immunodeficiency virus infection appears to present at a relatively young age.

This study aimed to evaluate the incidence of submandibular gland metastases in cases of oral cavity squamous cell carcinoma.

Sixty-nine patients treated between 1 January 2004 and 30 June 2009 were retrospectively reviewed. Patients were treated with wide local excision of the primary tumour, plus simultaneous neck dissection and reconstruction if required.

Of 69 submandibular glands from 46 men and 23 women (mean age, 58 years), 43 (62.3 per cent) had advanced, tumour stage three or four lesions. Histopathological reappraisal of all submandibular glands demonstrated an absence of metastatic spread. Only 2/69 (2.9 per cent) submandibular glands demonstrated ipsilateral contiguous tumour involvement.

This study demonstrated an absence of metastasis to the submandibular gland from oral cavity squamous cell carcinoma. Patients with early stage oral cavity squamous cell carcinoma and with a pre-operative node stage zero neck may be candidates for preservation of the submandibular gland during neck dissection.

To identify those patients most at risk of developing a compressive post-operative haematoma following thyroid surgery.

Retrospective analysis of patients undergoing thyroid surgery. Factors associated with the group of patients who developed a post-operative haematoma were examined using a matched pairs, case–control design.

Following 355 thyroid operations, seven patients developed a post-operative haematoma requiring return to the operating theatre for bleeding control. A post-operative systolic blood pressure of greater than 150 mmHg, in the post-anaesthetic care unit, was the major significant factor identified by regression analysis (p = 0.002). Current smoking status was also a significant factor (p = 0.04).

In our facility, a post-anaesthetic systolic blood pressure in excess of 150 mmHg was associated with an increased risk of haemorrhage following thyroid surgery.

Traditionally, a 1-cm surgical resection margin is used for early oral tongue tumours.

All tumour stage one (n = 65) and stage two (n = 13) oral tongue cancers treated between January 1999 and January 2009 were followed for a median of 38 months (minimum 12 months). The sites of close and involved margins were histologically reviewed.

Involved and close margins occurred in 14 and 55 per cent of cases, respectively. The number of involved vs clear or close margins was equivalent in tumour stage one (90 vs 82 per cent), node-negative (100 vs 84 per cent) and perineural or lymphovascular invasion (20 vs 21 per cent) cases. Close or involved margins were similarly likely to be posterior (59 per cent) as anterior (41 per cent, p = 0.22), lateral (57 per cent) as medial (43 per cent, p = 0.34), and mucosal (59 per cent) as deep (41 per cent, p = 0.22). Local recurrence occurred in 28 per cent of cases at a median of 12 months, and was more likely in cases with involved (50 per cent) than clear or close margins (25 per cent, p = 0.10). Disease-free survival was worse in involved margins cases (p = 0.002).

Involved margins are common in early tongue tumours, and are associated with increased local recurrence and worse survival. Close or involved margins occur in all directions and all tumour types. A wider margin may be justified.

To determine (1) the accuracy of positron emission tomography – computed tomography in the diagnosis of head and neck cancer, (2) the learning curve involved, and (3) whether its use alters patient management.

A retrospective study including 80 patients with head and neck cancer who underwent positron emission tomography – computed tomography image fusion at Blackpool Victoria Hospital.

Fifty-three patients underwent positron emission tomography – computed tomography for staging (32 for detection of a primary tumour and 21 for detection of distant metastasis) and 27 for detection of loco-regional recurrence. Ten primary tumours and 20 recurrences were accurately diagnosed by this method. Eighteen patients had their tumour stage and management modified as a result of this method of imaging. The effect of the learning curve resulted in better true positive detection rates, one year after introduction (81 versus 61 per cent). The sensitivity and specificity of this method in detecting head and neck cancer were 70 and 42 per cent, respectively, whereas those of conventional imaging were 73 and 51 per cent, respectively.

Compared with magnetic resonance imaging, the benefits of positron emission tomography – computed tomography may be limited to diagnosis of recurrence, as it is less hindered by tissue fibrosis, radiotherapy-related oedema, scarring and inflammation.

We examined the accuracy of magnetic resonance imaging in assessing thyroid cartilage and thyroid gland invasion in patients undergoing total laryngectomy for squamous cell carcinoma, by comparing histopathology results with imaging findings.

A retrospective study reviewed histology and magnetic resonance scan results for all total laryngectomies performed between 1998–2008 at University Hospital Aintree, Liverpool.

Pre-operative magnetic resonance images were reviewed independently by two consultant head and neck radiologists masked to the histology; their opinions were then compared with histology findings.

Eighty-one magnetic resonance scans were reviewed. There were 22 laryngectomy patients with histologically verified thyroid cartilage invasion and one patient with thyroid gland invasion. There were 31 patients with apparent radiological thyroid cartilage invasion pre-operatively (with 17 false positives), giving sensitivity, specificity, and positive and negative predictive values of 64, 71, 45 and 84 per cent, respectively. On assessing thyroid gland invasion, there were nine false positive scans and no false negative scans, giving sensitivity, specificity, and positive and negative predictive values of 100, 89, 10 and 100 per cent, respectively.

Magnetic resonance scanning over-predicts thyroid cartilage and gland invasion in patients undergoing total laryngectomy. Magnetic resonance scans have limited effectiveness in predicting thyroid cartilage invasion by squamous cell carcinoma in laryngectomy patients.

Description of a female patient with diagnosed Kjer's disease and sensorineural hearing loss, who specifically complained of a progressive inability to understand speech in noisy situations.

Case report.

A 30-year-old, Caucasian woman with Kjer's disease.

Audiological assessment showed low-frequency sensorineural hearing loss and a disproportionate deterioration in speech discrimination. This inconsistency gave rise to suspicion of possible aggravation. Follow-up testing showed that brainstem responses were absent, while clear otoacoustic emissions and cochlear microphonics were present. Hearing aids were fitted but no improvement was shown.

This case shows a combination of auditory neuropathy and Kjer's optic neuropathy. It also illustrates that the combination of unexplained hearing loss and apparently inconsistent audiometric outcomes may be associated with auditory neuropathy. Such unexpected hearing evaluation outcomes may be due to other neurological conditions, such as Kjer's disease.

To demonstrate the need for computed tomography imaging of the temporal bone before considering revision stapes surgery in patients with recurrent or residual conductive hearing loss.

We report the case of a high-riding jugular bulb with an associated jugular bulb diverticulum, which was dehiscent towards the vestibular aqueduct, in a patient with confirmed otosclerosis who did not experience hearing improvement after stapedotomy.

This case demonstrates the usefulness of temporal bone computed tomography in the evaluation of patients with otosclerosis in whom stapedotomy has not improved hearing. In such patients, revision surgery to address residual hearing loss would eventually prove unnecessary and avoidable.

We report an interesting case involving a child with a branchial cleft anomaly with two fistulous tracts, one of which was associated with an unusual otoscopic finding.

A seven-year-old girl presented with an apparent type II first branchial cleft cyst after an acute infection. Parotidectomy and excision of the tract were performed, with subsequent development of pre-auricular swelling three months later. Further surgery was performed to remove a second duplication anomaly of the external auditory canal. Otomicroscopy showed a fibrous band arising from the wall of the canal and attached to the tympanic membrane at the umbo.

Otoscopic findings on physical examination can be important diagnostic clues in the early recognition of branchial cleft anomalies. The classification system proposed by Work may fail to describe some branchial cleft lesions.