This paper discusses our technique of carrying out cervical and ocular vestibular-evoked myogenic potential testing in a single position. The described technique allows for a symmetrical, natural flexion of the neck muscles, which is helpful as many of our patients have suffered traumatic deceleration injures.

Patients with suspected vestibular pathology referred by specialists were sequentially assessed in a tertiary referral neuro-otology unit within a teaching hospital using our technique and our previously established normative database. All patients underwent standardised vestibular assessment in addition to cervical and ocular vestibular-evoked myogenic potential assessment. Our normative data are in keeping with that reported by other centres.

Many of the patients had abnormal vestibular-evoked myogenic potentials, which is in line with a history suggesting otolithic disease.

Both cervical and ocular vestibular-evoked myogenic potentials offer several parameters for detecting abnormalities. The technique reported enables us to assess patients in an accurate fashion whether or not they have suffered traumatic neck injuries.

Co-Phenylcaine Forte is a nasal spray routinely prescribed by otolaryngologists in Australia. The taste of Co-Phenylcaine Forte is typically described as unpleasant. This study sought to improve the overall patient experience associated with Co-Phenylcaine Forte by generating a Co-Phenylcaine Forte formulation, referred to as Co-Phenylcaine Zest, which contains an added vanilla flavour and masking agent.

Participants were randomised to receive two actuations of Co-Phenylcaine Forte in each nostril followed by two actuations of Co-Phenylcaine Zest, or vice versa. There was a 6–36-hour washout period between each treatment. After the administration of each spray, participants completed a questionnaire to rate various sensory attributes of each formulation on seven-point ordinal scales. Patients reported their overall formulation preference after receiving both treatments.

A total of 86 participants completed the trial. Seventy-four per cent of patients preferred Co-Phenylcaine Zest, 21 per cent preferred Co-Phenylcaine Forte and 5 per cent had no preference (p < 0.001). The satisfaction score associated with Co-Phenylcaine Zest was 1.22 points greater than with Co-Phenylcaine Forte (p < 0.001).

A novel formulation of Co-Phenylcaine Forte was created by adding a flavour and a masking agent; this formulation was preferred by most patients.

A subset of patients with bone-anchored hearing aids develop skin reactions that may be related to excess skin mobility around the skin-penetrating abutments. However, there is a lack of reports on the extent of skin mobility within the retroauricular space, typical for the implant location.

This study was based on photographic analysis of the relative shifts between the skull and soft tissue of the head in the retroauricular region, detected under the physiological conditions of head support and facial muscle contraction.

The mean calculated value for skin shifts at the implant site was 5.1 mm. In 84 per cent of cases, the extent of skin shift was greater with the head at rest, by an average of 3.1 mm. The extent of skin movement during facial muscle contraction ranged between 0 mm and 8.9 mm. No direct correlations were detected between the extent and direction of skin shifts and patients’ age, gender or body mass index.

There are no objective data that can predict individual skin movement at the osseointegrated implant site. The study confirmed high variability in terms of the direction and extent of skin shift, which should be discussed when managing related skin problems.

To compare combined conventional Freer medialisation and controlled synechiae, performed for middle meatal access (during the initial steps of functional endoscopic sinus surgery) and post-operative middle turbinate medialisation, with basal lamella relaxing incision, the latter of which is a single step for achieving both middle meatal access and post-operative medialisation. The study also compared the effects of controlled synechiae and basal lamella relaxing incision on post-operative olfaction.

A randomised prospective study was performed on 52 nasal cavity sides (32 patients). Only basal lamella relaxing incision was performed in one group, and both conventional medialisation and controlled synechiae were performed in the other. Intra-operative and post-operative photography was used to measure the middle meatal area. A pocket smell test was used to assess olfaction.

There were no significant differences in operative middle meatal access and post-operative medialisation of the middle turbinate. Post-operative olfaction was affected more in the combined conventional medialisation and controlled synechiae group, compared to the basal lamella relaxing incision group, but this finding was not statistically significant.

Basal lamella relaxing incision is an effective single-step technique for achieving adequate middle meatal access and post-operative medialisation, with no significant effect on olfaction.

To explore the link between nasal polyposis, refractory otitis media with effusion and eosinophilic granulomatosis with polyangiitis.

A retrospective observational study was carried out of patients diagnosed with refractory otitis media with effusion necessitating grommet insertion and who had nasal polyps. Patients were evaluated to determine if they fulfilled the diagnostic criteria of eosinophilic granulomatosis with polyangiitis.

Sixteen patients (10 males and 6 females) were identified. The mean age of grommet insertion was 45.4 years. The mean number of grommets inserted per patient was 1.6. The mean number of nasal polypectomies was 1.7. All 16 patients had paranasal sinus abnormalities and otitis media with effusion, 14 had asthma, 9 had serological eosinophilia and 7 had extravascular eosinophilia. Nine patients met the diagnostic criteria for eosinophilic granulomatosis with polyangiitis.

The co-presence of nasal polyps and resistant otitis media with effusion should raise the possibility of eosinophilic granulomatosis with polyangiitis.

Microscopic myringoplasty is the most frequently performed procedure for repairing tympanic membrane perforations. The endoscopic transcanal approach bypasses the narrow ear canal segment and provides a wider view.

An open-label randomised clinical trial was conducted on 56 patients with small anterior tympanic membrane perforations. Perforations were repaired with an endoscopic push-through technique (n = 28) or a microscopic underlay technique (n = 28). Follow up was conducted using endoscopic examination and pure tone audiometry three months’ post-operatively.

Graft success rate was 92.9 per cent in the endoscopic group versus 85.7 per cent in the microscopic group. The corresponding pre-operative mean air–bone gaps were 17.4 dB and 18.5 dB, improving to 6.1 dB and 9.3 dB post-operatively (p > 0.05). Mean air–bone gap closure was 11.4 dB in the endoscopic group and 9.2 dB in the microscopic group (p > 0.05). Mean operative time and estimated blood loss were 37.0 minutes and 29 ml in the endoscopic group, versus 107 minutes and 153 ml in the microscopic group (both p < 0.05).

The endoscopic push-through technique for anterior tympanic membrane perforations is as effective as microscopic underlay myringoplasty; furthermore, it is less invasive and takes less operative time.

Chronic suppurative otitis media is a massive public health problem in numerous low- and middle-income countries. Unfortunately, few low- and middle-income countries can offer surgical therapy.

A six-month long programme in Cambodia focused on training local surgeons in type I tympanoplasty was instigated. Qualitative educational and quantitative surgical outcomes were evaluated in the 12 months following programme completion. A four-month long training programme in mastoidectomy and homograft ossiculoplasty was subsequently implemented, and the preliminary surgical and educational outcomes were reported.

A total of 124 patients underwent tympanoplasty by the locally trained surgeons. Tympanic membrane closure at six weeks post-operation was 88.5 per cent. Pure tone audiometry at three months showed that 80.9 per cent of patients had improved hearing, with a mean gain of 17.1 dB. The trained surgeons reported high confidence in performing tympanoplasty. Early outcomes suggest the local surgeons can perform mastoidectomy and ossiculoplasty as safely as overseas-trained surgeons, with reported surgeon confidence reflecting these positive outcomes.

The training programme has demonstrated success, as measured by surgeon confidence and operative outcomes. This approach can be emulated in other settings to help combat the global burden of chronic suppurative otitis media.

To compare the outcomes of endoscopic repair of bilateral congenital choanal atresia using a flap technique without stenting versus endoscopic repair using stenting without a flap.

A prospective randomised controlled study was conducted, comprising 72 patients with bilateral congenital choanal atresia. The patients were randomised into two groups. Group A (42 patients) underwent endoscopic repair using a mirrored L-shaped flap without stenting, and group B (30 patients) underwent endoscopic repair using stenting without a flap.

At a mean follow-up period of 18.2 months, endoscopic assessment revealed a patent posterior choana in 81 per cent and 83.33 per cent of patients in group A and group B respectively. Choanal stenosis occurred in 21.40 per cent and 33.33 per cent of patients in group A and group B respectively. Granulation tissue was observed in 28.6 per cent and 53.3 per cent of patients in group A and group B respectively.

The endoscopic approach utilising a flap without stenting is safe and effective, with a high success rate.

Post-operative bleeding in the head and neck area is potentially fatal. This ‘real world’ study sought to assess factors that increase the risk of re-operation for post-operative bleeding in head and neck cancer surgery.

A total of 456 patients underwent surgery for head and neck cancer (591 operations). The primary endpoint was re-operation for bleeding.

The rate of re-operation for bleeding was 5 per cent of all operations. Re-operation for bleeding was an independent risk factor for 30-day mortality (odds ratio = 5.27, p = 0.014). Risk factors for re-operation because of bleeding included excessive (more than 4000 ml) fluid administration (over 24 hours) (p < 0.001), heavy alcohol consumption (p = 0.014), pre-operative oncological treatment (p = 0.017), advanced disease stage (p = 0.020) and higher tumour (T) classification (p = 0.034). Operations with more excessive bleeding (700 ml or more) were associated with an increased risk (p = 0.001) of re-operation for post-operative bleeding. Moreover, the risk of re-operation was significantly higher in patients undergoing microvascular surgery compared to those who had no oncological treatment pre-operatively (18 vs 6 per cent, p = 0.001).

The 30-day mortality risk increased over 5-fold in patients undergoing re-operation for bleeding.

Work describing patient and family outcomes after tracheostomy has indicated that patients do not feel prepared at the time of discharge.

To assess healthcare professional–patient interactions in tracheostomy care and the current provision of care.

A global electronic survey was disseminated via e-mail.

The majority of respondents were nursing or speech and language staff, from over 10 countries. Only 23 per cent of respondents’ institutions routinely offered patients the ability to meet people with a tracheostomy pre-operatively. Only 31 per cent consistently provided or co-ordinated full nursing and equipment requirements on discharge. Only half of the institutions participated in tracheostomy quality improvement initiatives; less than one-third of these involved patients.

The provision of tracheostomy care in hospital and at discharge can be improved. The current practice of clinician-led audit is becoming less viable; future initiatives should focus upon patient-centred outcomes to ensure excellence in healthcare delivery.

To ascertain the feasibility of endoscopic (4 mm) stapedotomy, and compare intra- and post-operative variations with microscopic stapedotomies.

Forty otosclerosis patients were scheduled for microscopic or endoscopic stapedotomy. Intra-operative variables compared were: incision, canalplasty, canal wall curettage for ossicular assessment, chorda tympani manipulation, ability to perform stapes footplate perforation before its supra-structure removal, and operative time. Post-operative variables compared were ear pain and hearing improvement.

Of the 20 microscopy patients, 4 required endaural incision and canalplasty because of canal overhangs, and 7 required canal wall curettage for ossicular assessment. None of the 20 endoscopy patients required these procedures. Chorda tympani was manipulated in 13 and 6 patients in the microscopy and endoscopy groups respectively, while the stapes footplate could be perforated in 5 and 11 patients respectively. Mean operative time was 50.25 and 76.05 minutes in the microscopy and endoscopy groups respectively. In the endoscopy group, mean air–bone gap was 37.12 and 10.73 dB pre- and post-operation respectively; in the microscopy group, these values were 35.95 and 13.81 dB.

Endoscopic stapedotomy has comparable hearing outcomes. Sinonasal endoscope serves as a better tool for: minimal incision, canalplasty avoidance, less chorda tympani mobilisation, and stapes footplate perforation ability.

The role of panendoscopy in the modern investigation of head and neck cancer is changing with the development of improved radiological techniques, in-office biopsy capabilities and the low rate of synchronous primary tumours. This study aimed to review the indications for panendoscopy in the investigation of newly diagnosed head and neck cancer.

A retrospective review was conducted of 186 patients with newly diagnosed head and neck cancer, between January 2014 and December 2015, at two tertiary centres.

Obtaining a tissue diagnosis was the most common indication for panendoscopy (65 per cent), followed by surgical planning including transoral robotic surgery suitability assessment (22.6 per cent), and the investigation of carcinoma of an unknown primary (11.3 per cent). Two synchronous primary tumours were identified, generating a yield of 1.1 per cent.

Panendoscopy remains integral in the assessment of transoral robotic surgery suitability. Refining indications for modern panendoscopy could reduce the need for this procedure in this cohort of patients.

Bacterial infection is a common finding in acute sialadenitis and may play a role in the chronicity of the condition. This study investigated if bacterial biofilm is present in submandibular chronic obstructive sialadenitis.

A descriptive case–control study was conducted that compared 10 histological sections of submandibular glands with chronic obstructive sialadenitis, to 10 histological sections of the healthy part of submandibular glands with pleomorphic adenoma. Fluorescence in situ hybridisation and confocal laser scanning microscopy visualised evidence of bacterial biofilm.

In the chronic obstructive sialadenitis group, 5 out of 10 histological sections showed morphological evidence of bacterial biofilm. In the control group, there was no sign of bacterial biofilm formation.

Morphological evidence of bacterial biofilm was found in the submandibular gland sections from patients with chronic sialadenitis and suggests a role in the chronicity of submandibular chronic obstructive sialadenitis.

Oropharyngeal squamous cell carcinoma is thought to rarely metastasise to bone. This study hypothesised that in p16-positive disease there is a significant incidence of bony metastasis.

This was an ambispective cohort review. All patients with oropharyngeal squamous cell carcinoma diagnosed and treated at one centre were included.

A total of 180 consecutive patients were identified over 5 years. Fifteen patients were excluded because of lack of p16 status, none of whom had bony metastasis. The final analysis included 165 patients: 48 (29.09 per cent) in the p16-negative group and 117 (70.91 per cent) in the p16-positive group. Ten patients (8.55 per cent) in the p16-positive group developed bony metastasis, compared with zero in the p16-negative group; this difference was statistically significant (p = 0.036).

Expression of p16 was associated with an increased incidence in bony metastasis in this cohort. This is the first study to explore this specific question.

This prospective, controlled study assessed how placing a stent into a newly formed ostium affects ostial patency, success and complication rates in endoscopic dacryocystorhinostomy patients.

In group 1 (40 eyes of 36 patients), both silicone tube intubation and tube stenting were performed. In group 2 (36 eyes of 34 patients), only silicone tube intubation was performed. Success, operative time and post-surgical complications were investigated two months post-operatively in each group.

The success rates were 92.5 per cent and 83.3 per cent for groups 1 and 2 respectively, but the difference was not statistically significant (p = 0.294). The complication rates also differed between the two groups, but this was again insignificant.

Compared with the use of a silicone tube alone, the addition of an ostial stent did not significantly increase the success rate of endoscopic dacryocystorhinostomy.

Steroid nasal irrigation for chronic rhinosinusitis patients following endoscopic sinus surgery reduces symptom recurrence. There are minimal safety data to recommend this treatment. This study evaluated the safety of betamethasone nasal irrigation by measuring its impact on endogenous cortisol levels.

Participants performed daily betamethasone nasal irrigation for six weeks. The impact on pre- and post-intervention serum and 24-hour urinary free cortisol was assessed. Efficacy was evaluated using the 22-item Sino-Nasal Outcome Test.

Thirty participants completed the study (16 females and 14 males; mean age = 53.9 ± 15.6 years). Serum cortisol levels were unchanged (p = 0.28). However, 24-hour urinary free cortisol levels decreased (47.5 vs 41.5 nmol per 24 hours; p = 0.025). Sino-Nasal Outcome Test scores improved (41.13 ± 21.94 vs 23.4 ± 18.17; p < 0.001). The minimal clinical important difference was reached in 63 per cent of participants.

Daily betamethasone nasal irrigation is an efficacious treatment modality not associated with changes in morning serum cortisol levels. The changes in 24-hour urinary free cortisol levels are considered clinically negligible. Hence, continued use of betamethasone nasal irrigation remains a viable and safe treatment option for chronic rhinosinusitis patients following functional endoscopic sinus surgery.

To evaluate the plasma levels of endothelial cell-specific molecule-1 (ESM-1) and pentraxin-3 (PTX-3) in patients with idiopathic sudden sensorineural hearing loss, and to compare the pre- and post-treatment levels in patients responsive and non-responsive to therapy.

The study included 108 subjects: 51 with idiopathic sudden sensorineural hearing loss and 57 controls. For ESM-1 and PTX-3 analyses, blood samples were collected before and three months after treatment initiation in the idiopathic sudden sensorineural hearing loss group and once for the control group. Treatment response was evaluated three months after therapy initiation with pure tone audiometry, and the patients were divided into two groups: responsive and non-responsive to treatment.

Serum ESM-1 levels were significantly higher in the idiopathic sudden sensorineural hearing loss group than the control group, whereas the difference was not significant for PTX-3. In the responsive and non-responsive groups, ESM-1 and PTX-3 levels were not statistically different before and after treatment.

To our knowledge, this is the first study investigating plasma ESM-1 and PTX-3 levels in idiopathic sudden sensorineural hearing loss. Increased plasma ESM-1 levels may confirm endothelial dysfunction involvement in idiopathic sudden sensorineural hearing loss pathogenesis, which could be associated with vascular impairment.

Head and neck space infections present with a potential mortality rate of 40–50 per cent. This paper proposes an algorithm-based management of head and neck space infection to prevent life-threatening events.

A total of 225 patients with head and neck space infection were prospectively analysed at our institution. An experimental scoring system determined the level of clinical risk for the development of major complications. Accordingly, patients were classified into three risk groups: low-, intermediate- and high-risk.

Only intermediate- and high-risk patients were hospitalised. Intermediate-risk patients received intravenous medical therapy with daily re-evaluation; 18 of them required delayed surgery. Of the high-risk patients, three required immediate surgical treatment and five received delayed surgery, while in five cases medical therapy was the only treatment received. Low-risk patients were treated in an out-patient setting.

The algorithm-based management of head and neck space infection was successful in enabling the avoidance of lethal complications onset.

To identify epidemiological and pathophysiological factors, and treatment strategies, in external auditory canal cholesteatoma and benign necrotising otitis externa.

A retrospective case study was conducted of patients suffering from external auditory canal cholesteatoma and benign necrotising otitis externa admitted to tertiary hospitals, in the Capital Region of Denmark, over a five-year period.

Eighty-three patients (95 ears) with external auditory canal cholesteatoma or benign necrotising otitis externa were identified. A minimum incidence rate of 0.97 per 100 000 inhabitants per year was demonstrated. Sixty-eight per cent of cases had a history of smoking. Most lesions (74 per cent) were localised in the floor of the ear canal. Treatment time was 3.2 months for patients who had surgery and 6.0 months for those who received conservative treatment.

It is suggested that external auditory canal cholesteatoma and benign necrotising otitis externa are in fact the same disease, and therefore the diagnosis of external auditory canal cholesteatoma should be changed to benign necrotising otitis externa. Microangiopathy has a leading role in the aetiology. Surgery should be conducted in most cases.

Tonsillectomy is a common procedure with significant post-operative pain. This study was designed to compare post-operative pain, returns to a normal diet and normal activity, and duration of regular analgesic use in Coblation and bipolar tonsillectomy patients.

A total of 137 patients, aged 2–50 years, presenting to a single institution for tonsillectomy or adenotonsillectomy were recruited. Pain level, diet, analgesic use, return to normal activity and haemorrhage data were collected.

Coblation tonsillectomy was associated with significantly less pain than bipolar tonsillectomy on post-operative days 1 (p = 0.005), 2 (p = 0.006) and 3 (p = 0.010). Mean pain scores were also significantly lower in the Coblation group (p = 0.039). Coblation patients had a significantly faster return to normal activity than bipolar tonsillectomy patients (p < 0.001).

Coblation tonsillectomy is a less painful technique compared to bipolar tonsillectomy in the immediate post-operative period and in the overall post-operative period. This allows a faster return to normal activity and decreased analgesic requirements.