An eight-year-old boy was presented with complaints of serous discharge from his left cheek since birth. As part of the radiological investigation, magnetic resonance imaging, computed tomography sialography with fistulography, and digital sialography with fistulography were performed.

Magnetic resonance imaging demonstrated the exact location of an accessory parotid gland but failed to demonstrate the accessory duct. The presence of an accessory gland was well delineated on computed tomography fistulography and computed tomography sialography. Fistulography revealed a small accessory parotid duct and gland. No communication between the ductal systems of both glands was demonstrated.

In such cases, pre-operative imaging (with sialography, magnetic resonance sialography and computed tomography sialography with fistulography) is helpful for exact delineation of the ductal anatomy. To the best of our knowledge, only four previous cases of congenital accessory parotid gland fistula have been reported in the English literature.

We present a 38-year-old man with a tension pneumo-orbit following medial orbital wall fracture, managed with endoscopic decompression.

A case report and a review of the world literature concerning the aetiology, clinical features and management of medial orbital wall fractures are presented.

Our patient presented with a post-traumatic tension pneumo-orbit exacerbated by air travel and nose-blowing. Computed tomography revealed a fracture of the ethmoid bone, and intra-orbital emphysema causing proptosis. Management with endoscopic, endonasal surgery produced excellent results, with decompression achieved and immediate and sustained improvement in visual acuity.

A search of the world literature revealed no documented cases of tension pneumo-orbit as a complication of medial orbital wall fracture. Endoscopic sinus surgery is currently used in the management of nasal and sinus diseases and their orbital complications. We discuss this extended indication of endoscopic surgery, and its advantages over other surgical approaches.

We report a rare case of Proteus syndrome which presented with dysphagia due to unilateral tonsillar hypertrophy.

Our case had involvement of multiple organs in addition to bony deformities, namely, enlarged right parotid gland and right testis, verrucous naevus, varicose veins and abdominal lipoma. The features unique to this case were a larger right optic disc and expansion of the inner table of the skull.

A literature review revealed less than 100 bona fide, published cases which fit the revised diagnostic criteria proposed by Turner.

The ENT manifestations of Proteus syndrome are high arched palate, gingival hypertrophy, malocclusion and overcrowding of teeth, hyperostosis of the external auditory meatus, and low nasal bridge. Our patient had a unilateral enlargement of the tonsil causing dysphagia, which was relieved by tonsillectomy.

We report a rare case of otological presentation of craniopharyngioma.

Case report and review of world literature concerning presentations of craniopharyngioma.

A six-year-old girl was referred to our department with unilateral hearing loss. This appeared to be a complete sensorineural hearing loss. Otoacoustic emissions were reproducible on both sides. Magnetic resonance scanning revealed a massive, cystic craniopharyngioma exerting pressure on the patient's ventricular system and brainstem and also invading the internal acoustic canal. The mass was resected via a craniotomy. The patient's hearing loss completely recovered, and she experienced no neurological or endocrinological side effects of the treatment. Craniopharyngioma have a prevalence of 0.13–2:100 000.

Craniopharyngioma is a rare disease. First presentation with otological symptoms is extremely rare. Otoacoustic emissions can differentiate between cochlear and retrocochlear causes of sensorineural hearing loss.

Larsen's syndrome is primarily known as an orthopaedic disease. However, it has been found to be associated with conductive hearing loss caused by ossicular malformation. The possibility of a sensorineural hearing impairment as an additional part of this syndrome has been rather neglected in the past.

Case report and literature review.

We present a teenage boy suffering from typical Larsen's syndrome. Despite no history of recurrent middle-ear infections, he showed a bilaterally symmetrical, mixed hearing loss dominated by an extensive sensorineural component. In order to review the corresponding literature, a Medline search was performed using the criteria ‘Larsen's syndrome’ and ‘hearing loss/deficit’.

The literature review showed the presented case to be the first sufficiently documented report describing a predominant sensorineural hearing loss in a Larsen's syndrome patient. Although a specific association of Larsen's syndrome with sensorineural hearing loss is still speculative, this case might give grounds for further examinations of this rare finding.

Our aim was to examine the presentation, complications and hospital course in this patient population, and to ascertain whether these patients had long term otological problems.

We retrospectively reviewed the medical records of all patients presenting with acute mastoiditis between January 1990 and December 2005. Patients' parents were contacted by telephone and questioned about further otological problems.

Twenty-nine patients were included in the study, and 27 of these patients' parents were contactable to complete the telephone questionnaire. Sixty-nine per cent of children had no previous history of acute otitis media prior to presentation. Forty-five per cent of patients had received oral antibiotics prior to presentation. Sixty-two per cent of patients developed complications, i.e. a subperiosteal abscess or failure to respond to medical therapy, resulting in the need for surgical intervention (in the form of incision and drainage of periosteal abscess, cortical mastoidectomy, or grommet insertion). Mean follow up of patients was eight years and one month; five (17 per cent) patients had been followed up for less than one year. Two (7 per cent) patients developed a further episode of mastoiditis within six weeks of initial presentation, both of whom required cortical mastoidectomy. Three (10 per cent) patients had further problems with recurrent acute otitis media, requiring tympanostomy tube insertion. One patient required a modified radical mastoidectomy for cholesteatoma (15 years later). Twenty-two patients (91 per cent) had been followed up for longer than one year; these patients had subjectively normal hearing and were asymptomatic at the time of study.

The majority of patients who had suffered an episode of acute mastoiditis had no adverse long term otological sequelae.

We question the need for packing of the ear canal after ear surgery. For several years, it had not been the first author's standard practice to use post-operative ear packing. During this period, few problems or complications had been encountered.

Tertiary referral, academic, paediatric hospital.

A retrospective review of all children who had undergone major ear surgery in our unit over the last year was carried out. These cases represented a full range of otological procedures. Post-operative complications and infections in the first six post-operative weeks were recorded.

A total of 135 ears were operated upon in 107 patients ranging in age from 11 months to 19 years (mean 9.5 years). During this time period, eight children (7.5 per cent) developed a post-operative ear infection. No cases of tympanic or meatal granulations, problems with the tympanomeatal flap, or meatal stenosis were encountered. All infections were successfully managed with topical antibiotics.

We conclude that packing after ear surgery may be safely abandoned. This would not only save valuable operating time, but would also obviate the need for pack removal, always a source of discomfort and anxiety. This is especially important in children, who may subsequently require a further general anaesthesia in order to remove the pack.

To assess the effectiveness and determine the compliance to a local protocol for requesting magnetic resonance imaging scans to screen for the presence of cerebellopontine angle lesions.

A combined retrospective study of all patients who had magnetic resonance imaging scans requested six months prior to and one year following introduction of the protocol and assessment of the true positive and false negative rate of the protocol by assessment of its sensitivity in cases referred from outside the department.

Comparison of the number of scans in each period showed a reduction in annualised rate of 142 to 46. The incidence of positive scans was the same in both periods, increasing the true positive rate from 1.4 to 4.3 per cent. The false negative rate was 1.1 per cent.

The Charing Cross protocol has a good compliance rate within the department, has reduced the cost of screening for cerebellopontine angle lesions and has an acceptable true positive and false negative rate.

Allergic rhinitis has traditionally been classified into seasonal and perennial rhinitis. However, many subjects with dual sensitisation do not fit neatly into either category. Recently, the Allergic Rhinitis and its Impact on Asthma workshop has proposed a new allergic rhinitis classification, into intermittent and persistent forms. The purpose of the present study was to investigate whether the symptomatic and secretory responsiveness of allergic rhinitis sufferers correlated well with the Allergic Rhinitis and its Impact on Asthma classification, compared with the traditional classification.

Experimental study.

Forty subjects with allergic rhinitis and 13 normal controls underwent a unilateral nasal bradykinin challenge protocol. Symptom scores were recorded and secretion weights measured bilaterally using filter paper disks. The symptomatic and secretory responses of allergic subjects were analysed according to both the traditional and the Allergic Rhinitis and its Impact on Asthma classifications, and the two systems were compared.

For both classification systems, the two groups of allergic subjects were clearly demarcated by secretory responses. However, after classification according to the traditional system, there was a lack of clear demarcation between the groups as regards symptomatic response, whereas clear demarcation of symptomatic responses was seen after using the Allergic Rhinitis and its Impact on Asthma classification.

In allergic rhinitis subjects, the degree of nasal responsiveness was closely related to their Allergic Rhinitis and its Impact on Asthma classification. Furthermore, this classification was not compromised by the inclusion of subjects with dual sensitisation. Thus, the Allergic Rhinitis and its Impact on Asthma classification may have advantages for future research studies on allergic rhinitis.

This study investigated the extent to which the anterior ethmoidal artery and anterior ethmoidal foramen could be reliably identified on routine coronal sinus computed tomography scans. Where they could be identified, the relationship of these structures with the vertical height of the skull base, and their distance from an anterior landmark, were measured.

Fifty consecutive coronal sinus computed tomography scans were viewed independently by two observers. Scans were reviewed when the observers' opinions differed.

Inter-observer concordance was high. The anterior ethmoidal foramen was visualised in 95 per cent of cases bilaterally and in the remaining 5 per cent unilaterally. The anterior ethmoidal artery was visualised in 33 per cent of scans. The anterior ethmoidal foramen was at skull base level in 72 per cent of sides studied, and below it in the remainder. The distance from the lacrimal crest to the anterior ethmoidal foramen was 22.4 mm (mean; standard deviation 3.7).

The anterior ethmoidal foramen is a reliable landmark on coronal computed tomography scans of the paranasal sinuses. From this, the position of the anterior ethmoidal artery can be inferred.

Chronic inflammation of sinus mucosa is a multifactorial condition which sometimes results in irreversible pathological mucosal changes.

To evaluate the efficacy of endoscopic radical antrectomy in treating chronic, hyperplastic, eosinophilic sinusitis, and to compare this procedure with classical endoscopic middle meatal antrostomy.

A randomised, controlled trial with parallel design was conducted between July 2000 and December 2004, including 119 patients who fulfilled the clinical, radiological and histopathological criteria for chronic, hyperplastic, eosinophilic sinusitis. Patients were randomly allocated to two treatment groups: classical endoscopic middle meatal antrostomy and endoscopic radical antrectomy. The main outcome measures were recorded in each subgroup at the time of the patient's last clinic visit. In each subgroup, these included subjective improvement and evaluation of the endoscopic appearance of the maxillary sinus.

Thirty-two per cent of patients in the endoscopic middle meatal antrostomy group were considered surgical failures, compared with 14.5 per cent of the endoscopic radical antrectomy group. This was statistically significant (p = 0.023). Unhealthy maxillary sinuses were significantly more prevalent in the endoscopic middle meatal antrostomy group (p = 0.029).

In those patients fulfilling the criteria suggestive of chronic, irreversible sinonasal pathology, primary endoscopic radical antrectomy was significantly better than endoscopic middle meatal antrostomy, based on subjective and objective findings.

The aim of this study was to evaluate the outcomes of therapeutic intervention in patients with mutational falsetto, by applying perceptual and acoustic analysis before and after voice therapy.

Forty-five consecutive patients with mutational falsetto were studied retrospectively. Acoustic analysis (i.e. fundamental frequency, jitter, shimmer, and formants one, two and three) was performed using the Multi-Dimensional Voice Program. Perceptual voice analyses were performed, including graded severity–roughness–breathiness–aesthenicity–strain assessment.

Subjects' fundamental frequency, voice formants one, two and three, jitter, and shimmer were greater before than after treatment. There were statistically significant differences between pre- and post-treatment average values for fundamental frequency, jitter and shimmer. There were also statistically significant differences between pre- and post-treatment average values for formants one and two. These results were maintained after six months of follow up, and there was no significant difference between results at three- and six-month follow up. According to perceptual evaluation, each subject's voice had altered from mutational falsetto to chest voice by completion of the intervention. Thus, all of the patients successfully lowered their modal speaking voice to an appropriate level.

In the light of objective evaluations, and by applying the study treatment protocol, these results suggest that normal voice can be maintained after intervention, at six months' follow up.

Coblation tonsillectomy is a relatively recently introduced surgical technique which attempts to bridge the gap between ‘hot’ and ‘cold’ tonsillectomy methods.

To compare coblation tonsillectomy with three commonly used surgical techniques: cold dissection–ligation, monopolar electrocautery and CO2 laser.

A prospective, randomised, double-blinded clinical trial was undertaken of 60 adult patients divided into three equal study groups. Patients in each group were randomly assigned to have one tonsil removed with coblation and the second with one of the other three tonsillectomy techniques. Ten randomly selected tonsils resected by each method were sent for histopathological evaluation.

Coblation was significantly faster to perform than laser and produced significantly less intra-operative blood loss than both the dissection–ligation and laser techniques. Subjective visual analogue scale comparisons showed a non-significant pain score difference between coblation and dissection–ligation on most post-operative days. Coblation produced consistently highly significantly (p < 0.001) less pain, compared with electrocautery up to the 12th post-operative day and laser up to the 10th post-operative day. There was no significant difference in tonsillar fossa healing, comparing coblation to both dissection–ligation and laser techniques. Monopolar electrocautery produced significantly slower healing than coblation after 7 post-operative days, with no significant difference after 15 post-operative days. Histopathological evaluation showed that coblation inflicted significantly less thermal tissue injury than either electrocautery (p = 0.001) or laser (p = 0.003).

In adult patients, coblation tonsillectomy offers some significant advantages in terms of post-operative pain and healing, compared with other tonsillectomy techniques.

Thyroid nodules are frequently present in Graves' disease. The aim of this study was to evaluate the risk of thyroid carcinoma in Graves' disease patients, with and without ultrasonographically identified nodules, who subsequently underwent surgical treatment.

The study group included 150 consecutive patients with diagnosed Graves' disease who subsequently underwent surgery.

The patients were divided into two groups according to whether the pre-operative ultrasound scan showed diffuse parenchyma (group one; n = 70) or nodules (group two; n = 80).

Of the 150 patients, 18 (12 per cent) were found to have papillary thyroid carcinoma. Papillary carcinoma was found in seven patients (10 per cent) in group one and in 11 patients (1.7 per cent) in group two. After evaluating the overall groups, the incidence of carcinoma in the parenchyma outside a nodule was 67 per cent, whereas the incidence of carcinoma in a nodule was 33 per cent.

Carcinoma can occur in Graves' disease patients without nodules, and the absence of nodules on ultrasonographic examination does not reduce the risk of malignancy.

Non-attendance at out-patient clinics is a seemingly intractable problem, estimated to cost £65 (€97) per incident. This results in under-utilisation of resources and prolonged waiting lists. In an effort to reduce out-patient clinic non-attendance, our ENT department, in conjunction with the information and communication technology department, instigated the use of a mobile telephone short message service (‘text’) reminder, to be sent out to each patient three days prior to their out-patient clinic appointment.

To audit non-attendance rates at ENT out-patient clinics following the introduction of a text reminder system.

Retrospective review.

Non-attendance at our institution's ENT out-patient clinics was audited, following introduction of a text message reminder system in August 2003. Rates of non-attendance were compared for the text message reminder group and a historical control group.

Before the introduction of the text message reminder system, the mean rate of non-attendance was 33.6 per cent. Following the introduction of the system, the mean rate of non-attendance reduced to 22 per cent.

Sending text message reminders is a simple and cost-effective way to improve non-attendance at ENT out-patient clinics.