In Pakistan, oral cancer ranks as the most common malignancy in males and the second most common malignancy in females. Cyclooxygenase-2 has been explored as an agent of carcinogenesis in oral and other neoplasms. This study aimed to observe the expression of cyclooxygenase-2 in oral squamous cell carcinoma, and to correlate the expression with patients’ clinical features and overall and disease-free survival.

Immunohistochemistry for cyclooxygenase-2 was performed on a total of 100 oral squamous cell carcinoma formalin-fixed, paraffin-embedded blocks. Expression was correlated with patients’ clinicopathological variables and overall and disease-free survival.

Cyclooxygenase-2 was overexpressed in 55 per cent of oral squamous cell carcinoma patients. Overexpression was correlated with overall survival (p = 0.013) and disease-free survival (p = 0.001) on univariate analysis. However, on multivariate analysis, cyclooxygenase-2 was associated with only disease-free survival (p = 0.044) and not overall survival (p = 0.208).

Expression of cyclooxygenase-2 is associated with poorer overall survival and higher rates of recurrence in oral squamous cell carcinoma patients.

Eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis show variable otorhinolaryngological involvement. Up to 14 per cent of granulomatosis with polyangiitis patients have subglottis involvement; little is known about the laryngeal involvement in eosinophilic granulomatosis with polyangiitis.

A literature review was conducted, together with a prospective cross-sectional analysis of 43 eosinophilic granulomatosis with polyangiitis patients. All patients underwent fibre-optic laryngoscopy with narrow-band imaging, and completed health-related questionnaires.

The literature review showed only two cases of laryngeal involvement in eosinophilic granulomatosis with polyangiitis; in our cohort, no cases of subglottis stenosis were found, but local signs of laryngeal inflammation were present in 72 per cent of cases. Of the patients, 16.2 per cent had a pathological Reflux Finding Score (of 7 or higher).

Laryngeal inflammation in eosinophilic granulomatosis with polyangiitis is frequent. It is possibly due more to local factors than to eosinophilic granulomatosis with polyangiitis itself. However, ENT evaluation is needed to rule out possible subglottis inflammation. These findings are in line with current literature and worthy of confirmation in larger cohorts.

This study aimed to evaluate the presence of subjective post-operative donor site morbidity after fibula free flap reconstruction in head and neck cancer patients, utilising three validated instruments: the 36-item Short Form Health Survey, the Short Musculoskeletal Function Assessment questionnaire and the Lower Limb Core Scale.

In this retrospective study, all head and neck cancer patients who underwent fibula free flap reconstruction between January 2009 and July 2014 were identified. All questionnaires and their respective subcomponents were scored.

Twenty-one cases were included. Patients were found to have a higher Short Musculoskeletal Function Assessment bothersome index (22.42 vs 13.77, p = 0.03), a lower Short Form 36 Health Survey Physical Component Summary score (42.44 vs 50, p < 0.01) and a decreased Lower Limb Core Scale score (47.08 vs 90.52, p < 0.01), compared to US population norms. The Short Form 36 Health Survey Mental Component Summary scores and Short Musculoskeletal Function Assessment function index failed to demonstrate significant differences. Gender affected overall disability.

In this study, significant long-term disability was demonstrated after fibular flap reconstruction, as measured by the Lower Limb Core Scale.

To explore the risk factors associated with the occurrence of synchronous oesophageal cancer in patients with hypopharyngeal cancer, and to investigate the roles of image-enhanced endoscopic screening in the prediction and diagnosis of early oesophageal cancer.

The clinical characteristics of patients with hypopharyngeal cancer (n = 160) were analysed. All patients underwent laryngoscopic and gastroscopic examination using image-enhanced endoscopic techniques before treatment.

Of 160 hypopharyngeal cancer patients, 43 (27 per cent) had synchronous oesophageal cancer. Heavy drinking (odds ratio = 4.787, p = 0.029) and local invasion of three or more anatomical sites (odds ratio = 14.391, p = 0.000) were independent risk factors for synchronous oesophageal cancer. Narrow-band imaging laryngoscopy could detect more invaded anatomical sites than ordinary white light endoscopy (t = 8.532, p = 0.000). More early oesophageal cancer cases were detected with Lugol chromoendoscopy than with non-Lugol iodine staining examination (χ2 = 4.925, p = 0.026).

Synchronous oesophageal cancer is common in patients with hypopharyngeal cancer. The heavy drinking patients with hypopharyngeal cancer should undergo intensive monitoring. Image-enhanced endoscopic screening is helpful in the prediction and early detection of second primary oesophageal cancer.

To quantitatively test the hypothesis that older patients have increased thyroarytenoid muscle atrophy by comparing thyroarytenoid muscle volumes across different age groups.

A retrospective chart review was conducted. The study included 111 patients with no history of laryngeal pathology. Two investigators reviewed magnetic resonance imaging studies of these patients and manually traced the thyroarytenoid muscles on multiple slices bilaterally. Thyroarytenoid muscle volumes were then computed using imaging analysis software. Patients were stratified into three age groups (18–50 years, 51–64 years, and 65 years or older) for comparison.

Intra- and inter-rater reliabilities were excellent for all measurements (intraclass correlation co-efficient > 0.90). There was no statistically significant difference in the mean volumes of left and right thyroarytenoid muscles in all age and gender groups.

Given the lack of statistically significant difference in thyroarytenoid muscle volume between age groups on magnetic resonance imaging, the prevailing assumption that age-related thyroarytenoid muscle atrophy contributes to presbyphonia should be re-examined.

Necrotising otitis externa can be a devastating form of otitis externa. It typically tends to affect patients who are immunocompromised or diabetic. To date, there is very little in the literature about necrotising otitis externa in the immunocompetent patient population.

The present paper discusses both the clinical and radiological findings in three cases of necrotising otitis externa in an immunocompetent patient cohort. The common factor among all three patients was their advanced age.

Diagnosing necrotising otitis externa can be challenging because of the potentially non-specific symptoms and the absence of early radiological signs, particularly if patients are neither immunocompromised nor diabetic. Elderly patients should be considered in the same light as immunocompromised and diabetic patients in the context of necrotising otitis externa.

To determine: (1) the incidence of incidental ‘mastoiditis’ reported on magnetic resonance imaging scans performed in patients with asymmetrical sensorineural hearing loss and/or unilateral tinnitus; (2) how many of those patients have actual otological pathology and/or require treatment; and (3) the financial implications of such a reporting practice.

Retrospective case series.

Between October 2015 and November 2016, 500 patients underwent magnetic resonance imaging of the internal auditory meatus to rule out cerebellopontine angle lesions. There was an incidental finding of increased mastoid signalling in 5.8 per cent (n = 29), of which 20.7 per cent (6 of 29) were reported as bilateral cases. The diagnosis of ‘mastoiditis’ was found in 39.7 per cent (29 of 73). None of these patients had any pathology identified clinically. Other significant pathology was identified in a further 8.8 per cent (n = 44).

The diagnosis of mastoiditis is primarily clinical. An incidental finding of high signalling in the mastoid region on magnetic resonance imaging is highly unlikely to represent actual clinical disease. In patients who are scanned for other reasons and who do not complain of otological symptoms, such findings are unlikely to require otolaryngology input.

To assess the feasibility of using cumulative sum analysis to show trainees’ performance curves and highlight concerns in tonsillectomy surgery.

In this prospective study, the performance of eight otolaryngology trainees (in their first 6–12 months in the specialty) was compared to that of experts (over 150 tonsillectomies performed) in terms of operative time and post-operative complications. Cumulative sum analysis curves were generated to highlight trainees’ performance, and were updated after each performance.

The average operative time was 23 minutes (standard deviation = 11) for experts and 38 minutes (standard deviation = 16) for trainees (p < 0.0001). Cumulative sum analysis charts for trainees’ operative time initially rose and then started to plateau after a number of cases (range, 25–30), while that of experts remained low. Cumulative sum analysis charts for complications can be used to monitor performance. In this study, complications were combined (because of low incidence) to allow use of this outcome measure.

The flexibility of the cumulative sum analysis makes it adaptable to any outcome. It is a strong adjunct in surgical training to monitor progress and competence. Its sensitivity also allows early detection of poor performance, to instigate intervention.

To evaluate the efficacy and safety of segmental superficial parotidectomy in the surgical treatment of benign parotid tumours.

Patients who underwent parotidectomy for benign primary parotid tumours limited to the superficial lobe were retrospectively reviewed. Tumour location, size, surgical procedure, follow-up period, complications and recurrence rates were noted.

The study included a total of 39 patients: 22 underwent segmental superficial parotidectomy (group 1) and 17 underwent superficial parotidectomy (group 2). The mean follow-up period was 41.79 months (range, 13–85 months). There were no recurrences in either group during the follow-up period. No significant differences were found between the two groups in terms of tumour size, complications or recurrence rates.

Segmental superficial parotidectomy is a safe and effective option in the surgical treatment of benign parotid tumours.

Neck dissection is associated with post-operative shoulder dysfunction in a substantial number of patients, affecting quality of life and return to work. There is no current UK national practice regarding physiotherapy after neck dissection.

Nine regional centres were surveyed to determine their standard physiotherapy practice pre- and post-neck dissection, and to determine pre-emptive physiotherapy for any patients.

Eighty-nine per cent of centres never arranged any pre-emptive physiotherapy for any patients. Thirty-three per cent of centres offered routine in-patient physiotherapy after surgery. No centres offered out-patient physiotherapy for all patients regardless of symptoms. Seventy-eight per cent offered physiotherapy for patients with any symptoms, with 11 per cent offering physiotherapy for those with severe dysfunction only. Eleven per cent of centres never offered physiotherapy for any dysfunction.

The provision of physiotherapy is most commonly reactive rather than proactive, and usually driven by patient request. There is little evidence of pre-arranged physiotherapy for patients to treat or prevent shoulder dysfunction in the UK.

The imaging of stones in the salivary glands and ducts poses a challenge, even to experienced ultrasound examiners. This study investigated whether the ‘twinkling artefact’, which occurs at internal calcific foci during Doppler ultrasound examinations, is useful for detecting salivary gland stones.

In a model test, 20 salivary stones were analysed in vitro, via Doppler ultrasound, with regard to their representability and the triggering of the twinkling artefact. In a follow-up study, 28 patients with sialolithiasis and food-related large salivary gland swellings were examined, using both power and colour Doppler modes, with regard to the twinkling artefact. All ultrasound examinations were performed by an experienced examiner and retrospectively graded by two experienced sonographers.

All stones could reliably be detected using the twinkling artefact in the model test. Twenty-seven of 28 salivary stones (96 per cent) also showed twinkling in vivo, during patient assessment. The power Doppler mode showed a significantly higher intensity level of twinkling than the colour Doppler mode (p < 0.0001).

The twinkling artefact is a very reliable sign for the diagnosis of sialolithiasis. Power Doppler is superior to colour Doppler for detection of the twinkling artefact.

To date, there is a lack of consensus regarding the use of both computed tomography and magnetic resonance imaging in the pre-operative assessment of cochlear implant candidates.

Twenty-five patients underwent high-resolution computed tomography and magnetic resonance imaging. ‘Control scores’ describing the expected visualisation of specific features by computed tomography and magnetic resonance imaging were established. An independent radiological review of all computed tomography and magnetic resonance imaging scan features was then compared to the control scores and the findings recorded.

Agreement with control scores occurred in 83 per cent (20 out of 24) of computed tomography scans and 91 per cent (21 out of 23) of magnetic resonance imaging scans. Radiological abnormalities were demonstrated in 16 per cent of brain scans and 18 per cent of temporal bone investigations.

Assessment in the paediatric setting constitutes a special situation given the likelihood of congenital temporal bone abnormalities and associated co-morbidities that may be relevant to surgery and prognosis following cochlear implantation. Both computed tomography and magnetic resonance imaging contribute valuable information and remain necessary in paediatric cochlear implant pre-operative assessment.

To characterise subjective symptoms in patients undergoing surgical repair of superior semicircular canal dehiscence.

Questionnaires assessing symptom severity and impact on function and quality of life were administered to patients before superior semicircular canal dehiscence surgery, between June 2011 and March 2016. Questionnaire sections included general quality of life, internal amplified sounds, dizziness and tinnitus, with scores of 0–100 points.

Twenty-three patients completed the questionnaire before surgery. Section scores (mean±standard deviation) were: 38.2 ± 25.2 for general quality of life, 52.5 ± 23.9 for internal amplified sounds, 35.1 ± 28.8 for dizziness, 33.3 ± 30.7 for tinnitus, and 39.8 ± 22.2 for the composite score. Cronbach's α statistic averaged 0.93 (range, 0.84–0.97) across section scores, and 0.83 for the composite score.

The Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire provides a holistic, patient-centred characterisation of superior semicircular canal dehiscence symptoms. Internal consistency analysis validated the questionnaire and provided a quantitative framework for further optimisation in the clinical setting.

To investigate the effectiveness and usability of automated procedural guidance during virtual temporal bone surgery.

Two randomised controlled trials were performed to evaluate the effectiveness, for medical students, of two presentation modalities of automated real-time procedural guidance in virtual reality simulation: full and step-by-step visual presentation of drillable areas. Presentation modality effectiveness was determined through a comparison of participants’ dissection quality, evaluated by a blinded otologist, using a validated assessment scale.

While the provision of automated guidance on procedure improved performance (full presentation, p = 0.03; step-by-step presentation, p < 0.001), usage of the two different presentation modalities was vastly different (full presentation, 3.73 per cent; step-by-step presentation, 60.40 per cent).

Automated procedural guidance in virtual temporal bone surgery is effective in improving trainee performance. Step-by-step presentation of procedural guidance was engaging, and therefore more likely to be used by the participants.

This study investigated the incidence and routes of submandibular gland involvement in oral cavity carcinoma to determine the feasibility of submandibular gland sparing neck dissection.

The records of 155 patients diagnosed with oral cavity squamous cell carcinoma, with a total of 183 neck specimens, including those involving level I, were reviewed retrospectively.

Submandibular gland involvement, via direct invasion from the anatomical proximity of T4a tumours, was evident in two patients. The floor of mouth location, either primarily or as an extension of the primary tumour, was the only risk factor for submandibular gland involvement in oral cavity carcinoma (p = 0.042). Tumour location, clinical and pathological tumour (T) and nodal (N) stages, and radiological suspicion of mandible invasion, were not found to be statistically relevant (p > 0.05).

The results suggest the feasibility of preserving the submandibular gland in early stage oral cavity carcinoma unless the tumour is located in, or extends to, the floor of mouth.

To assess arterial spin labelling and diffusion-weighted imaging in the differentiation of recurrent head and neck cancer from post-radiation changes.

A retrospective study was conducted of 47 patients with head and neck cancer, treated with radiotherapy, who underwent magnetic resonance arterial spin labelling and diffusion-weighted magnetic resonance imaging. Tumour blood flow and apparent diffusion co-efficient of the lesion were calculated.

There was significant difference (p = 0.001) in tumour blood flow between patients with recurrent head and neck cancer (n = 31) (47.37 ± 16.3 ml/100 g/minute) and those with post-radiation changes (n = 16) (18.80 ± 2.9 ml/100 g/minute). The thresholds of tumour blood flow and apparent diffusion co-efficient used for differentiating recurrence from post-radiation changes were more than 24.0 ml/100 g/minute and 1.21 × 10−3 mm2/second or less, with area under the curve values of 0.94 and 0.90, and accuracy rates of 88.2 per cent and 88.2 per cent, respectively. The combined tumour blood flow and apparent diffusion co-efficient values used for differentiating recurrence from post-radiation changes had an area under the curve of 0.96 and an accuracy of 90.2 per cent.

Combined tumour blood flow and apparent diffusion co-efficient can differentiate recurrence from post-radiation changes.

Although melioidosis in the head and neck region is uncommon, it is a potentially life-threatening infection. Thus, early diagnosis and proper management are very important.

To report the clinical presentation and management of melioidosis in the head and neck.

A retrospective study was conducted from 1 January 2013 to 31 October 2016 in Mukdahan Hospital, Thailand. Case records of patients who had presented with culture-positive melioidosis were analysed.

Medical records of 49 patients (23 males and 26 females) were analysed. Patients ranged in age from 1 to 75 years. Clinical presentations included 22 parotid abscesses, 16 neck abscesses and 11 suppurative lymphadenitis cases. Only 35 patients (71 per cent) had high indirect haemagglutination assay titres of ≥ 1:160 (95 per cent confidence interval = 45.35–88.28). Almost half of the patients received intravenous ceftazidime and subsequently oral co-trimoxazole. Oral antibiotic regimens were prescribed for mild localised melioidosis. Overall, 95.65 per cent of patients were in remission and no relapses were observed (95 per cent confidence interval = 85.47–98.80).

Careful clinical correlation and proper investigation are required to establish an early diagnosis of melioidosis and to initiate appropriate treatment.

To conduct a cost analysis of injection laryngoplasty performed in the operating theatre under local anaesthesia and general anaesthesia.

The retrospective study included patients who had undergone injection laryngoplasty as day cases between July 2013 and March 2016. Cost data were obtained, along with patient demographics, anaesthetic details, type of injectant, American Society of Anesthesiologists score, length of stay, total operating theatre time and surgeon procedure time.

A total of 20 cases (general anaesthesia = 6, local anaesthesia = 14) were included in the cost analysis. The mean total cost under general anaesthesia (AU$2865.96 ± 756.29) was significantly higher than that under local anaesthesia (AU$1731.61 ± 290.29) (p < 0.001). The mean operating theatre time, surgeon procedure time and length of stay were all significantly lower under local anaesthesia compared to general anaesthesia. Time variables such as operating theatre time and length of stay were the most significant predictors of the total costs.

Procedures performed under local anaesthesia in the operating theatre are associated with shorter operating theatre time and length of stay in the hospital, and provide significant cost savings. Further savings could be achieved if local anaesthesia procedures were performed in the office setting.

To highlight a case from 1960 connecting endolymphatic sac tumour and von Hippel–Lindau disease.

In 1960, a 24-year-old woman presented with unilateral hearing loss, pulsatile tinnitus and a mass visible on otoscopy. The patient underwent surgical biopsy, which was complicated by haemorrhage, and ultimately resulted in death. At autopsy, a destructive temporal bone neoplasm with cystic and papillary architecture was observed that had eroded into the otic capsule. Intra-abdominal lesions consistent with von Hippel–Lindau disease were also observed, and the surgeon postulated a connection between endolymphatic sac tumour and von Hippel–Lindau disease.

A review of the literature was carried out using PubMed.

Endolymphatic sac tumours are rare neoplasms of the temporal bone that can occur sporadically or as part of von Hippel–Lindau disease. The connection between endolymphatic sac tumour and von Hippel–Lindau disease was first proposed in 1988 and formalised in 1997. We believe that this case represents the first documented connection between endolymphatic sac tumour and von Hippel–Lindau disease.

This study aimed to determine the effect of the subperiosteal tight pocket technique versus the bone recess with suture fixation technique on the revision cochlear implantation rate and complications.

This retrospective study included 1514 patients who underwent cochlear implantation by 2 senior surgeons between October 2002 and January 2016. Revision cases were identified and analysed.

In all, 52 patients (3.34 per cent) underwent revision cochlear implantation. The revision rate was 7.18 per cent in the subperiosteal tight pocket group versus 2.37 per cent in the bone recess with suture fixation group (p < 0.001). Device failure was the most common reason for revision surgery in both groups. There was a significant difference in the device failure rate between the bone recess with suture fixation group (2.11 per cent) and subperiosteal tight pocket group (6.88 per cent) (p < 0.001).

Accurate fixation of the cochlear implant receiver/stimulator is crucial for successful cochlear implantation. As the bone recess with suture fixation technique is associated with a lower revision rate and a similar complication rate as the subperiosteal tight pocket technique, it should be the preferred fixation technique for cochlear implantation.