Objective: The purpose of this study was to investigate whether a new self-tapping implant for a bone-anchored hearing aid (BAHA) had the same high frequency of osseointegration as previous implants requiring pre-tapping.

Method: Over a three-year period, 144 consecutive implants were placed in the mastoid for BAHA and evaluated.

Results: Two implants were lost; both were of the self-tapping type. One was in an 11-year-old boy, who lost his implant six weeks after surgery when the BAHA was fitted. The other was in an elderly man, a heavy smoker with diabetes. Using Fisher's exact test, there was no significant difference between the two groups (p>0.30).

Conclusion: Self-tapping implants facilitate surgery and shorten operating time. Over a short follow up, we did not find any significant difference; however, it is important to follow these implants over a longer time period.

Objective: To assess whether lateral semicircular canal (LSCC) ossification is more advanced than that in the cochlear basal turn, in order to judge the value of the former as a predictor.

Methods: Retrospective review of 33 paediatric patients from our cochlear implant programme, with profound sensorineural hearing loss after bacterial meningitis. Magnetic resonance imaging (MRI), computed tomography (CT) scans and operative findings were reviewed.

Results: On CT, LSCC ossification scores were more advanced than those for the cochlear basal turn in 69.9 per cent of implanted ears. Forty-five per cent (15/33) of children had ossification at surgery. In predicting this, the sensitivity of CT LSCC ossification was 90 per cent and that of MRI LSCC ossification was 83.3 per cent.

Conclusions: The more advanced ossification found in the LSCC, compared with that in the cochlear basal turn, adds to previous findings of LSCC pathology predicting cochlear ossification. Surprisingly, CT of the LSCC appears to be no less valuable than MRI in pre-operative cochlear implant assessment of post-meningitic children.

Introduction: Wearing hearing aid earmoulds has been implicated as a predisposing factor in the development of chronic otitis externa. Audiologists come into contact with a large number of hearing aid earmoulds and these could potentially harbour pathogenic micro-organisms, with the risk of subsequent cross infection. Cleaning with dilute alcohol is widely used in an attempt to break the chain of infection.

Objective: To determine the presence and nature of microbial flora on hearing aid earmoulds and the efficacy of cleaning methods used to prevent cross infection.

Setting: Secondary health care within the audiology department of Addenbrooke's Hospital, Cambridge, UK.

Design: A prospective, observational study.

Methods: Hearing aid earmoulds were swabbed before and after cleaning. Samples were cultured to determine qualitatively and quantitatively the microbiological flora present before and after cleaning.

Results: Twenty out of 21 (95 per cent) earmoulds had microbes present and, of these, 19/20 (95 per cent) had a polymicrobial profile. Coagulase negative staphylococci and diphtheroids were the most frequent microbial isolates, but pathogenic bacteria and fungi were also demonstrated on earmoulds both before and after cleaning.

Conclusions: The polymicrobial flora, including recognized pathogens, that colonizes earmoulds may lead to chronic otitis externa. Cleaning with 70 per cent alcohol solution was ineffective, in particular for pathogenic fungi on earmoulds.

Facial palsy is a rare presenting feature of cholesteatoma. Prompt treatment usually results in a good outcome, but if treatment is delayed the prognosis can be difficult to predict. We retrospectively reviewed 326 consecutive patients who had undergone temporal bone surgery for cholesteatoma. Eleven patients had presented with facial palsy, of whom eight had petrous apex involvement and three had disease confined to the middle-ear cleft. All patients with middle-ear disease were operated upon within two months of presentation, and all showed some recovery in facial function. The diagnosis had been delayed in all eight cases of apical disease, with four cases having had a long-standing total weakness. One case treated after seven months' partial weakness achieved a full recovery. In three cases of long-standing partial weakness, pre-operative facial function was preserved by maintaining the facial nerve in its normal anatomical location.

Facial palsy associated with cholesteatoma should be treated as early as possible. Recovery can occur even if treatment is delayed for up to seven months. After this time, recovery is increasingly unlikely, but any residual function can be maintained and further deterioration prevented.

For fifteen years oral ciprofloxacin has been the standard treatment for malignant otitis externa, a sometimes fatal osteomyelitis of the skull base usually caused by Pseudomonas aeruginosa. Resistance to ciprofloxacin is developing. Over a 16-month period, we saw five cases where malignant otitis externa progressed, with the development of cranial nerve palsies in four cases, despite oral ciprofloxacin. Prolonged intravenous antibiotic therapy became necessary. One case was managed largely as an out-patient, but four patients spent many weeks in hospital. Only two cases had diabetes and this was monitored and controlled. Pseudomonas aeruginosa was isolated in four of the five cases, but antibiotic sensitivity to ciprofloxacin was not determined. In one case a later isolate was tested and found to be ciprofloxacin resistant. Progress was monitored by serial C-reactive protein (CRP) and white cell count. For diagnosis and assessing response to treatment we considered serial magnetic resonance imaging or computed tomography more useful than isotope bone scan. There must be a readiness to use intravenous antibiotics, as a response to ciprofloxacin can no longer be assumed. Bacterial isolates must be tested for sensitivity to antibiotics including ciprofloxacin, and further biopsy and culture are essential if treatment fails.

Objective: To examine the effects of oral diazepam on blood pressure and anxiety in patients with acute epistaxis.

Study design and setting: A prospective comparative study in an otorhinolaryngology tertiary referral centre.

Participants: Patients with acute epistaxis requiring hospital admission.

Intervention: Oral diazepam.

Main outcome measures: Anxiety and blood pressure levels.

Results: 32 patients received diazepam and 45 did not (control). On average, patients were hypertensive on admission (mean [standard deviation (SD)] systolic blood pressure diazepam group=157 mmHg [26], control=152 mmHg [23]; diastolic blood pressure diazepam group=87 mmHg [16], control=87 mmHg [18]). Both groups showed significant blood pressure reduction on discharge (p<0.0001) but the difference in mean blood pressure reduction between the two groups was insignificant (systolic blood pressure p=0.16, 95% confidence interval [CI]=–5 to +19 mmHg; diastolic blood pressure p=0.43, 95% CI=–8 to +10 mmHg). Anxiety was significantly lower on discharge (p<0.0001) but the difference in mean fall in anxiety scores between the two groups was insignificant (p=0.08, 95% CI=0 to +2). There was no significant correlation between total diazepam and changes in blood pressure (systolic blood pressure p=0.32; diastolic blood pressure p=0.65) or anxiety (p=0.73), nor between blood pressure and anxiety on admission (systolic blood pressure p=0.45; diastolic blood pressure p=0.72).

Conclusions: Elevated blood pressure and anxiety in acute epistaxis patients reduced on epistaxis resolution irrespective of oral diazepam use. The elevated blood pressure does not appear to be directly related to anxiety.

Background: Successful local anaesthesia is of critical importance for the success of septoplasty, and many surgeons prefer to use cocaine for this purpose. The aim of this study was to evaluate the efficacy of cocaine 4 per cent solution, compared with tetracaine 2 per cent plus adrenaline, as a local anaesthetic for patients undergoing septoplasty.

Methods: From December 2002 to February 2005, a prospective, randomized, controlled trial was conducted. One hundred and eight patients underwent septoplasty under local anaesthesia. Patients were randomly classified into group A and group B, in which was used respectively cocaine 4 per cent solution and tetracaine 2 per cent solution plus adrenaline. A visual analogue scale was used to evaluate the severity of patients' pain during their procedure.

Results: Group B (tetracaine; mean rank=43.77) reported significantly less pain (p<0.001) compared with group A (cocaine; mean rank=65.23).

Conclusions: On the basis of these findings, we recommend tetracaine as the first choice anaesthetic for nasal septoplasty; the use of cocaine should be limited.

Aim: To evaluate the effectiveness of an information leaflet in improving patient understanding of the procedure and complications of septoplasty.

Design: The baseline knowledge of a group of patients who had attended a pre-assessment clinic prior to septoplasty was assessed. The procedure and its complications were then verbally explained. The patients' knowledge was then re-assessed on the morning of surgery and any improvements noted. In the second arm of the study, an information leaflet was introduced at the time of verbal instruction and any differences in improvement in knowledge were assessed.

Results: Data from the two groups were analysed using an analysis of covariance with differences in baseline (pre-instruction) knowledge controlled. Additional improvements in mean recall score following leaflet distribution were highly statistically significant when compared with mean recall in the control group (p<0.001).

Conclusion: The use of information leaflets increases patients' knowledge about a surgical procedure and its potential complications.

Aims: To report on the use of holmium yttrium aluminium garnet (YAG) laser in the treatment of acquired posterior choanal atresia following radiotherapy in patients with nasopharyngeal carcinoma.

Materials and methods: Five patients with acquired bilateral choanal atresia and two with unilateral choanal atresia in the posterior choanae were identified following treatment of nasopharyngeal carcinoma by external radiotherapy, from July 1998 to April 1999. The mean age was 44.6 years (range, 22–65 years). Two patients had stage two and five had stage three disease according to Ho's classification. All patients received 66 Gy of external irradiation delivered to the nasopharynx and a mean dose of 61 Gy (39.8–72 Gy) to the neck. Five patients received an additional external boost of 20 Gy and two received 14 Gy delivered to the parapharyngeal region. Two other patients also received intracavitatory brachytherapy of 18 Gy delivered to the nasopharynx. One patient had concurrent chemotherapy by cisplatinum during external radiotherapy. The mean onset of nasal symptoms was 17 months (range, 2–38 months) following irradiation. All patients were treated by transnasal endoscopic holmium YAG laser resection. Merocel® epistaxis packing and a modified nasopharyngeal tube were used to stent the nasal airway for two weeks post-operatively.

Results: The mean follow up was 26.8 months (range, 20–32 months) after surgery. All patients were symptom free on follow up. Five patients (71 per cent) retained full patency in the posterior choanae. Two patients (28 per cent) had bilateral mild restenosis in the postnasal space, not requiring revision surgery. The surgical fields were almost bloodless. No adverse post-operative complications occurred, except for delayed nasal septal perforation in one patient and unilateral exposure of the septal cartilage in another; no further treatment was required in either patient.

Conclusion: Acquired posterior choanal atresia is an unusual complication following radiotherapy, and it can occur early after treatment. It can be successfully treated by transnasal endoscopic holmium YAG laser resection of the scar tissue, with minimal bleeding. A two week period of Merocel® nasal packing and nasopharyngeal tube stenting was sufficient to prevent severe restenosis in the posterior choanae; nasal breathing through the tube lumen was possible during this time.

Aims: To evaluate the results of chemotherapy alone in patients with invasive squamous cell carcinoma of the larynx who have achieved a complete clinical response after an induction chemotherapy protocol.

Methods: A comparison of results in a group of complete responders managed with a chemotherapy alone protocol, matched with those of an incomplete responder group managed with conventional modalities.

Results: The survival rate of the complete responder group was significantly higher than that of the incomplete responder group. No statistically significant difference was noted between the two groups in terms of local failure and nodal recurrence.

Conclusion: Our results confirm the fact that chemotherapy alone is a viable option in selected patients with carcinoma of the larynx who have achieved a complete clinical response after an induction chemotherapy protocol. This therapeutic approach allows surgery and/or radiation therapy to be reserved for the management of metachronous second primary tumours.

Background: Between 1 and 2 per cent of head and neck squamous cell carcinoma patients will reveal no evidence of a primary malignancy. The management of this group poses many problems, including the morbidity associated with wide field irradiation as well as the difficulty in treatment when a primary does emerge. The aim of this study was to assess the use of fluoro-deoxy-glucose positron emission tomography (FDG-PET) imaging in patients presenting with an unknown head and neck primary and to consider its routine use in such patients.

Methods: We enrolled 25 patients into our study over a four year period. They all presented with a histologically proven, metastatic, squamous cell carcinoma of the neck for which no primary could be found despite full clinical, endoscopic and radiological evaluation with computed tomography (CT) and/or magnetic resonance imaging (MRI). Additionally, all the patients underwent imaging using FDG-PET. The images were interpreted by two radiologists experienced in PET imaging.

Results: A primary was identified in nine of the 25 patients (42 per cent); however, of these patients, six had false positive results and only three patients were true positives with supportive histology. In the remaining 16 patients, no abnormality was identified on CT, MRI or PET. Of these 16 patients, two eventually displayed a primary carcinoma, the other 14 patients remaining without evidence of any primary.

Conclusion: Despite the high number of positive PET scans, the actual true positive rate was 3/9 (33 per cent); conversely, the true negative rate was 14/16 (88 per cent). We conclude from this study that there is a role for FDG-PET in the patient with an unknown head and neck primary, particularly in the context of a negative PET scan.

Head and neck squamous cell carcinoma is well known to be more common in men than women. Smoking and alcohol are the key risk factors causing such malignancies and there are several publications which have suggested that the prevalence of these diseases is increasing more in women than in men in western countries due to increased smoking and alcohol use.

We collected our data at the Institute of Laryngology and Otology from the last 45 years and analysed the disease ratios in male to female patients in different sites within the head and neck. Our results revealed a decreasing male to female ratio, though this was not statistically significant. However, it draws attention to the increasing number of women with head and neck cancer, which may reflect their increasing use of cigarettes and alcohol.

The importance of an adequate meatoplasty is often emphasised in mastoid surgery. However, bigger is not always better, as an excessively widened external meatus can be cosmetically unacceptable, provide little extra benefit for cleaning, be an obstacle to the good fitting of hearing aids and expose the mastoid cavity to exaggerated caloric effect.

The problems created by an overly large meatus can occasionally be difficult to manage, prompting consideration of reduction of the meatus. We describe the use of a pedicled, post-auricular skin flap to achieve reduction of an excessively large meatus.

A new image-guided microscope using augmented reality overlays has been developed. Unlike other systems, the novelty of our design consists in mounting a precise mini and low-cost tracker directly on the microscope to track the motion of the surgical tools and the patient. Correctly scaled cut-views of the pre-operative computed tomography (CT) stack can be displayed on the overlay, orthogonal to the optical view or even including the direction of a clinical tool. Moreover, the system can manage three-dimensional models for tumours or bone structures and allows interaction with them using virtual tools, showing trajectories and distances. The mean error of the overlay was 0.7 mm. Clinical accuracy has shown results of 1.1–1.8 mm.

Glossopharyngeal nerve paralysis caused by varicella zoster virus reactivation is rare. We present a case of glossopharyngeal zoster confirmed by direct immunofluorescence staining for virus antigens. A 35-year-old man presented with right-sided, severe swallowing pain and dysgeusia. Physical examination showed a loss of ipsilateral gag reflex. White spots on the posterior wall of the right pyriform sinus were seen by laryngofibroscopy, and a loss of taste on the right posterior part of the tongue was confirmed by gustometry using the filter paper disc method. The varicella zoster virus antigen was revealed by direct immunofluorescence staining by fluorescein isothiocyanate labelled mouse monoclonal antibody specific for varicella zoster virus glycoprotein, using samples obtained from the mucosal lesion by abrasion with a cotton swab. The patient was treated by intravenous administration of acyclovir. His throat pain and dysgeusia completely resolved. We discuss the advantages of direct immunofluorescence staining for varicella zoster virus antigen for the diagnosis of glossopharyngeal zoster.

Positional and positioning vertigo and nystagmus syndromes are usually due to peripheral vestibular dysfunction. The most common form is benign paroxysmal positioning. In this paper, we discuss more serious aetiologies in the differential diagnosis for patients presenting with a history suggestive of benign paroxysmal positioning vertigo. We draw attention to the diagnosis of cerebellar vermis lesions and tumours of the fourth ventricle by presenting two cases of patients with positional nystagmus of so called benign paroxysmal type. We review the literature on positional nystagmus, highlighting key findings on history and physical examination to aid in the correct diagnosis of benign paroxysmal positioning vertigo, and to differentiate it from the rare yet sinister central aetiologies that can present with positional vertigo of the benign positional type. This is with the aim to avoid over-investigating a common presentation without missing a serious diagnosis.

An extremely rare case of a granular cell tumour arising from the right Kiesselbach's area (Little's area) of the nasal septum is reported. A 69-year-old Japanese woman consulted our clinic and her chief complaints were of continuous serous discharge, stuffiness and occasional slight bleeding from the right nasal cavity. Fibrescopy showed a multilocular mass, which was provisionally considered a nasal polyp. Surgical excision was attempted. During surgery, the tumour shrank markedly following local application of adrenaline, suggestive of hypervascularity. The tumour was successfully excised by careful dissection after cauterisation of the mucosa surrounding the tumour. Histopathological examination revealed morphological features of granular cell tumour immunopositive for S-100 protein. This is the first report of granular cell tumour arising from the Kiesselbach's area in the English literature. The eccentric behaviour of the tumour and the management of a granular cell tumour arising from this area are discussed, together with a literature review.

Objectives: To demonstrate the importance of detailed clinical analysis in the differential diagnosis of unilateral vocal fold paralysis, and to provide an update on current knowledge and treatment of myasthenia gravis.

Case report: A female patient presented with left unilateral vocal fold immobility. Diagnostic investigation revealed a 10 mm thyroid adenoma, but no other abnormality likely to cause unilateral vocal fold paralysis. Follow-up flexible endoscopy at three months showed laryngeal remobilisation with persistent left vocal fold bowing and vertical asymmetry of the vocal folds on phonation. Over the following months, voice quality varied between normal and breathy, with the breathy periods lasting from three days to one month. Laryngeal electromyography (EMG) showed a slight bilateral paradoxical activation of both posterior crico-arytenoid muscles on phonation. Magnetic resonance imaging of the brain and brainstem was normal. A diagnostic test for myasthenia gravis with intravenous edrophonium bromide (Tensilon®) lead to an immediate improvement in voice quality. The patient was subsequently treated with pyridostigmine bromide, with complete resolution of dysphonia.

Conclusions: Myasthenia gravis affecting the larynx may mimic unilateral vocal fold paresis or paralysis. A personal or family history of auto-immune disease, fluctuating symptoms, motor deficits in cranial nerve territories, and normal or subnormal laryngeal EMG results should lead the physician to reconsider a diagnosis of idiopathic unilateral vocal fold paralysis and to perform specific testing.

We describe in this case report a new technique for treatment of hypopharyngeal haemangioma, using the surgical diathermy snare. The snare was easily introduced through the direct laryngoscope, without any difficulties. The procedure was simple, rapid and involved minimal bleeding. We also discuss the histological types of haemangioma, clinical picture, radiological findings and other modalities of treatment.

Treatment of salivary stones includes both surgical and non-surgical techniques. Surgical approaches range from excision of the sialolith, for those near the duct orifice, to removal of the affected salivary gland and its associated duct, for stones near the hilum of the gland. We present a case of two sialoliths triggering an acute infection in a residual Wharton's duct, 12 years after the removal of the associated submandibular gland. Excision of the sialoliths and treatment of the infected duct via sialodochoplasty was successfully performed in this patient. If the Wharton's duct is not removed with the associated submandibular gland, the potential for infection and continuous growth of dormant calcifications exists. We also address the aetiology, pathogenesis, and management of patients with sialolithiasis in the absence of a major salivary gland.