Difficult cerebellopontine angle (CPA) tumours namely large/giant vestibular schwannomas, vestibular schwannomas with a significant anterior extension and meningiomas of the posterior surface of the petrous bone extending anterior to the internal auditory canal (IAC) have always posed a problem for the otoneurosurgeon. Modifications of the enlarged translabyrinthine approach (ETLA) specifically aimed at dealing with these tumours are not reported. The aim of this paper is to introduce the transapical extension of ETLA which involves increased circumferential drilling around the IAC beyond 270°C. The extension allows enhanced surgical control over the tumour as well as the anterior aspect of the CPA including the prepontine cistern, the Vth and VIth cranial nerves. The extension is further classified into Type I and II depending upon the extent of drilling. Type I extension entails drilling around the IAC for 300–320° and is indicated for large/giant vestibular schwannomas (large vestibular schwannoma extrameatal diameter 3–3.9 cm, giant vestibular schwannoma extrameatal diameter [ges ]4 cm) and vestibular schwannomas with significant anterior extension. Type II extension involves complete drilling around the canal for 360° and is indicated for meningiomas of the posterior surface of the petrous bone extending anterior to the IAC.

Sistrunk’s procedure for thyroglossal duct remnants has a very high success rate, there remains the occasional patient, however, that will have recurrent disease despite a competently performed operation. Applied anatomy and embryology proffer a solution to this problem. Extending the Sistrunk operation, with an anterior wide local excision remaining within normal tissue, enables removal of the entire thyroglossal tract remnant.

A retrospective case note review was conducted to study our experience using this extended procedure to treat patients with thyroglossal tract disease that had recurred after a previous Sistrunk’s operation.

Six patients aged from five to 33 years were included in the study. There was one recurrence and the complication rate was comparable to the standard operation.

It was concluded that a wide local excision is a valuable extension of the Sistrunk operation for the management of recurrent disease.

The Provox® (Atos Medical AB, Hörby, Sweden) voice prosthesis was developed between 1988 and 1990 and has been used at our centre with regular success since 1993. Since 1996, a second generation of Provox® (Provox®2) has been used, which can be inserted by an anterograde technique. The aim of this study is to compare the survival lifetime of both voice prostheses. The survival time of the two voice prostheses were compared retrospectively in 152 devices placed in 38 patients. A Kaplan-Meier analysis was performed to determine the survival lifetimes and a log rank test was performed to compare the two curves. Clinical factors affecting the lifetime were also analysed with a Kaplan-Meier plot.

The median survival lifetime of the Provox® and Provox®2 were 303 and 144 days respectively. The Kaplan-Meier estimation shows that this difference is statistically significant (p=0.02). It is considered an early failure if it occurs within the first three months. There was a larger number of early failures with the Provox®2 than with the Provox® (p=0.04). Neither the gender nor the age affected the lifetime of the devices. Radiotherapy seemed to lengthen the lifetime of the first valve.

The survival lifetime of the second generation Provox®2 valve is shorter than the lifetime of the first generation Provox®. This could be due to the difference in elasticity of these valves that could lead to a different level of colonization and invasion of the valves by micro-organisms.

This paper attempts to evaluate the clinical usefulness of CYFRA 21-1 as a serum tumour marker in patients with head and neck squamous cell carcinoma (HNSCC).

The serum concentration of CYFRA 21-1 was measured utilizing a new electrochemiluminescent immunoassay (ECLIA) in 142 patients with HNSCC before and after treatment, 68 patients with benign tumours of the head and neck, and 50 healthy controls.

Serum levels of CYFRA 21-1 in patients with HNSCC were significantly higher than those of benign tumours and healthy controls (p < 0.001). The diagnostic sensitivity and specificity of CYFRA 21-1 for HNSCC were 62 per cent and 100 per cent, respectively. The positive rates of CYFRA 21-1 increased with progression of HNSCC, serum CYFRA 21-1 levels were related to the tumour stage expressed by primary tumour (T) and nodal status (N) (p < 0.001), but not related to patient age, gender, smoking and drinking habit, or histopathological grade (p > 0.05). Post-treatment levels of CYFRA 21-1 in HNSCC decreased significantly (p < 0.001). Among 38 patients with clinical or radiological evidence of a recurrence during follow-up, 78.9 per cent (30 of 38) showed an increase in CYFRA 21-1.

The analytical ECLIA performance for serum CYFRA 21-1 provides a new means of clinical assessment for HNSCC. The results of ECLIA suggest that the serum marker CYFRA 21-1 is valuable not only for diagnosis but also for close monitoring of patients with HNSCC.

The aetiopathogenesis of acute unilateral peripheral vestibular dysfunction (APV), also known as vestibular neuritis, is still debated: the principal cause is viral infection with vascular factors second in importance.

Plasmatic D-dimer, considered a plasmatic index of hypercoagulation, was measured in a group of 45 APV patients and in a group of 25 patients suffering from Ménière’s disease. Measurements were taken both during the acute stage and after a four to six week period of pharmacological washout. The mean D-dimer levels were significantly higher than those measured in the controls both during the acute phase (301 SD161 vs 202 SD113 ng/mL) and after follow up (304 SD211 vs 192 SD111 ng/mL) (p = 0.008). Moreover, during the acute stage 23 of the APV patients (51.1 per cent) had plasmatic D-dimer levels above the upper normal limit (i.e.: <300 ng/mL), compared to four of those with Ménière’s disease (16 per cent).

Our results lead us to postulate an involvement of the haemostatic system in APV.

The frequency of accessory sinus ostia (ASO) has been estimated at between four and 50 per cent in the findings of studies designed for other purposes or from uncontrolled observations. The literature revealed no study specifically designed to determine the prevalence of ASO. We have carried out a prospective cohort study to measure the prevalence of ASO.

The prevalence of ASO was determined in rhinology clinic patients and general ENT clinic controls. Overall ASO occurred in four per cent. Seven per cent of rhinology patients and two per cent of controls had ASO. Of the rhinology patients with rhinitis or sinusitis, eight per cent exhibited ASO. The overall prevalence in this study is lower than most quoted figures in the literature. There was increased prevalence of ASO in patients with rhinitis or sinusitis compared to controls. (p<0.05)

This study should be regarded as a pilot study and further investigations of the relationship between ASO and nasal disease is merited.

Patients commonly complain of discomfort at the angle of the mouth following tonsillectomy. This can be attributed to trauma sustained during the procedure. A prospective, patient-blinded, controlled trial of 34 tonsillectomies was performed using a protective, plastic oral guard. A blinded observer recorded postoperative pain and clinically evident trauma to the angle of the mouth. The patient group in whom the guard was used had a significantly lower incidence of labial trauma (p<0.002) and complained of pain less frequently (p<0.002) when compared with a control group in whom no guard was used. The use of a protective lip guard during tonsillectomy is recommended.

This was a prospective study and analysis of the clinical nature and severity of consultation, patient age and sex, place of consultation, grade of attending doctor and management strategy of in-patients referred for a specialist opinion to a Department of Otolaryngology.

Internal requests for consultation were evaluated at the North Manchester General Hospital between October 1999 and August 2000 (n=101).

Patients referred to the Otolaryngology department were of a varied clinical nature with head and neck complaints being the largest group. Forty-six of the patients had minor complaints.Patients were found to be predominantly male and older than 50 years of age. The grade of attending doctor was predominantly a Specialist Registrar and the management strategy was most frequently conservative.

Many of the requests for consultation were regarding minor problems that could be referred to a routine out-patient clinic. There is a need to improve the indication criteria for internalconsultation, as well as the information provided in them.

The use of photodynamic therapy for the treatment of malignant and non-malignant conditions is increasing. This paper demonstrates the efficacy of a second-generation photosensitizer, Foscan®, in the primary treatment of a wide range of mucosal head and neck squamous cell carcinomas. Tumours ranged in stage from T1 to T3. A complete response to primary treatment was seen in 19/21 patients (90 per cent). In laryngeal cancer recurrent after radical radiotherapy, one out of four patients treated obtained a complete response (25 per cent). Six patients (24 per cent) required surgery after photodynamic therapy, for local recurrence or dysplasia. Mean follow up was for 27.3 months (standard deviation 20.6 months).

The Groningen voice prosthesis can be successfully replaced using the back-loading system. We have attempted to minimize patient stress by developing a front-loading system that does not require insertion of the introducer via the tracheo-oesophageal shunt to the oral cavity or the mesopharyngeal anaesthetization regularly used with the back-loading system. Using our front-loading system, the existing prosthesis is removed, then the posterior portion of the replacement Groningen prosthesis is grasped by a pair of nasal forceps with a small jaw to make an acute angle and inserted into the oesophageal cavity through the shunt at a stroke. All 20 patients who underwent forward-loading replacement of a Groningen (n=17) or Blom-Singer (n=3) valve with a Groningen valve tolerated the procedure well and experienced no complications except, in some cases, for minor bleeding just after insertion of the prosthesis.The procedure was completed within 30 seconds.

Pain and secondary haemorrhage are the commonest complications of adult tonsillectomy, occurring mostly in the community. This is a randomized, double-blind, placebo-controlled, prospective trial of the effect of perioperative amoxycillin on these complications. The incidence and severity of post-operative haemorrhage was measured. For the first 10 post-operative days patients provided a linear pain score, a record of GP visits, and their use of additional antibiotics and analgesics.

Of 95 patients considered: 23 suffered a secondary haemorrhage; 54 consulted their general practitioner (GP) because of pain; additional antibiotics were used by at least 31 and additional analgesics by at least 41. No significant differences were demonstrated between the active and placebo groups for any of these measures.

This study demonstrates that secondary haemorrhage is common after adult tonsillectomy. Post-operative pain remains a major problem requiring frequent GP consultations. There appears to be no justification for the routine use of perioperative antibiotics.

We describe an endaural technique for soft tissue and bony meatoplasty and canalplasty in the surgical management of chronic otitis externa unresponsive to medical treatment and out-patient microsuction. Following analysis of the surgical outcome via a retrospective review of patient records, we would recommend this surgical treatment in this patient group.

Fine needle aspiration (FNA) of the tonsil as a diagnostic tool in evaluating the microflora in chronic tonsillitis has not been popularized. A prospective study of 30 patients with chronic tonsillitis undergoing tonsillectomy was undertaken. FNA of the tonsil core was done under local/general anaesthesia. The reliability of the culture by FNA of the tonsil core was then validated with the reference (gold) standard which is the dissected tonsil core. The sensitivity of FNA culture as compared to core culture was 100 per cent and 93 per cent under general and local anaesthesia respectively. The positive predictive value of FNA culture as compared to core culture was 92 per centand 82 per cent for general and local anaesthesia respectively. These factors indicate that FNA of the tonsil core is reliable and valid. It can safely be performed as an out-patient procedure under local anaesthesia. This is reported for the first time. Identifying the bacterial organism within the infected tonsil for appropriate antibiotic therapy could revolutionize the management of chronic tonsillitis.

The overall quality and delivery of patient care is becoming increasingly important, especially in those diagnosed with cancer. Multidisciplinary clinics are a valuable adjunct to this, but patients may not fully understand or comprehend all that is said to them. The use of audiotaping consultations has been studied in some settings, but not in head and neck cancer clinics. We report on a series of 50 consecutive head and neck patients to determine their views on the value of this facility. Thirty-nine patients (78 per cent) utilized the opportunity, of which 36 patients (92 per cent) found it beneficial. Over three quarters of the patients who used the facility thought that medical staff could benefit and learn from the tape recording. We recommend that audiotaping becomes a standard part of the multidisciplinary head and neck oncology clinic, helping to improve the overall quality of patient care.

A study was undertaken to determine whether the Provox® voice prosthesis provides good voice rehabilitation following a total laryngectomy in the urban, suburbanand rural populations served by a tertiary referral hospital in South Africa.

Between 1995 and 1999, a cohort of 128 patients at Tygerberg Hospital was rehabilitated with the Provox™ voice prosthesis after laryngectomy. In 104 patients primary placement of the prosthesis was done at the time of the laryngectomy. Mean device life and adverse events were determined. Voice quality was assessed subjectively in 104 patients and objectively in 26 patients.

The mean device life was 303 days and adverse events occurred in 16 patients. Subjectively, 77 of 104 patients had a good voice, and objectively 22 of 26 patients had good voice intelligibility. The Provox® voice prosthesis provides good voice rehabilitation following total laryngectomy, with minimal complications, in the population served by Tygerberg Hospital.

The study presents a comprehensive statistical analysis of a series of 500 consecutive rhinoplasties of which 380 (76 per cent) were primary and 120 (24 per cent) were secondary cases. All cases were operated upon using the external rhinoplasty technique; simultaneous septal surgery was performed in 350 (70 per cent) of the cases. Deformities of the upper two-thirds of the nose that occurred significantly more in the secondary cases included; dorsal saddling, dorsal irregularities, valve collapse, open roof and pollybeak deformities. In the lower third of the nose; secondary cases showed significantly higher incidences of depressed tip, tip over-rotation, tip asymmetry, retracted columella, and alar notching. Suturing techniques were used significantly more in primary cases, while in secondary cases grafting techniques wereused significantly more. The complications encountered intra-operatively included; septal flap tears (2.8 per cent) and alar cartilage injury (1.8 per cent), while post-operative complications included; nasal trauma (one per cent), epistaxis (two per cent), infection (2.4 per cent), prolonged oedema (17 per cent), and nasal obstruction (0.8 per cent). The overall patient satisfaction rate was 95.6 per cent and the transcolumellar scar was found to be unacceptable in only 0.8 per cent of the patients.

This was a study of the effect of functional endoscopic sinus surgery (FESS) on the ciliary regeneration of maxillary sinus mucosa in patients with chronic maxillary sinusitis, using objective quantitative methods. Twenty specimens from the mucosa of both the superolateral wall and the ostium of the maxillary sinus were sampled during FESS and then six to 12 months later. They were light examined first by light microscopy and then by scanning electron microscopy in combination with image analysis software in order to study the cilia under higher magnification and to calculate proportion of the field that was ciliated. Samples were taken and studied at Cairo University hospital. This study showed that the maxillary sinus mucosa in chronic sinusitis is capable of regeneration and could return towards normal with the improvement of ventilation and drainage of the maxillary sinus following FESS. There were no significant changes in the degree of glandular hyperplasia, goblet cells or pathological glands after surgery.

Anterior ethmoidal artery ligation is a well-established surgical procedure in the management of epistaxis. We describe a procedure of anterior ethmoidal artery ligation via minimal access external surgery with the use of a rigid endoscope. This is, as far as we are aware, the first description of an external approach endoscopic anterior ethmoidal artery ligation.

Rhinophyma is considered to be the final stage of rosacea and has an unknown aetiology. We present two new surgical adjuncts for the treatment of this condition. The microdebrider is easy to use and allows precise contouring of the nose. It shares the same underlying principle as free-hand scalpel shaving but outperforms this method in key areas. We also describe a novel use for FloSeal®, a gelatin-thrombin co-mixture, utilizing its haemostatic properties to address bleeding from the re-shaped denuded nose.

Acquired lacrimal fistula occurs in an improperly and inadequately treated lacrimal sac abscess. This study was done to evaluate the success of endoscopic dacryocystorhinostomy (EDCR) in treating such lacrimal fistula. A retrospective analysis of nine cases of acquired lacrimal fistulae in seven patients, treated by EDCR without any external surgery was carried out. Cessation of epiphora and closure of fistula were considered, successful outcomes. All the nine fistulae closed, and all patients were relieved of their epiphora within two weeks of surgery. It can be concluded that EDCR is effective for treating an acquired lacrimal fistula.