The treatment of allergic rhinitis has been revolutionized by the introduction of topical nasal steroids, which are one of the commonest prescriptions from otolaryngology departments. With so many different sprays available on the market, the literature was reviewed for the efficacy, side-effect profile and relative cost of each product and the following conclusions made:

(1) A meta-analysis of randomized controlled trials comparing the efficacy of intranasal corticosteroids and oral antihistamines in the treatment of allergic rhinitis showed a clear benefit in favour of intranasal steroids in relieving nasal symptoms.

(2) There is no clear evidence to support the suggestion that one steroid spray is more effective than another in the treatment of seasonal or perennial allergic rhinitis.

(3) All the sprays have a similar side-effect profile; the commonest being epistaxis with a reported incidence between 17 and 23 per cent. In all the clinical trials, the placebo spray had an appreciable rate of epistaxis of between 10 to 15 per cent.

(4) Fluticasone causes a reduction in endogenous cortisol secretion but no significant adrenal suppression was seen with triamcinolone, beclomethasone, budesonide or mometasone.

(5) There is little evidence that skeletal growth is restricted by the administration of topical nasal steroid sprays.

(6) There is considerable variation in the daily cost of each spray. Beclomethasone, dexamethasone and budesonide are significantly cheaper than fluticasone, mometasone or triamcinolone.

Ni-Ankh-Sekhmet has always been referred to as the first rhinologist in history. Translations of the hieroglyphics depicted on all the illustrations accompanying previous publications do not substantiate this claim. The research presented is a result of an investigation of the original monument related to the doctor at its present location in the Egyptian Museum, Cairo. The research proves that Ni-Ankh-Sekhmet was the first rhinologist in history.

Hearing threshold has been measured in a group of patients following cochlear implantation with a Clarion® device for the last eight years. The patients had received either a pre-curved carrier or the Hi-Focus I plus Electrode Positioner System (EPS). The assessment was carried out within the first post-operative week as well as at a later stage, between six and 87 months, post-operatively. Residual hearing thresholds were still measurable early after surgery in 24.5 per cent of the patients, without differences between the two different Clarion® models. However, the number of subjects with measurable hearing dropped to 16.3 per cent as observed when hearing was measured at a later stage, with an equal distribution between the two groups of patients. From this study it has been possible to observe that only a limited number of patients maintain residual hearing after Clarion® cochlear implantation, and that this tends to decrease further over time. Nevertheless, the performance of these patients for speech tests did not appear to be affected by deterioration of the pure-tone auditory threshold.

We investigated the eustachian tube function and the incidence of alternobaric vertigo (AV) in 29 sport self-contained underwater breathing apparatus (SCUBA) divers with, or without, some possible risk factors for AV. The divers had normal audiological and otoscopic findings at the pre-dive examination. We used the nine-step inflation/deflation tympanometric test and Toynbee test for evaluation of eustachian tube function, and the Valsalva manoeuvre for patency. Information on divers, their history, and their otolaryngologic examination were obtained in the pre-dive examination. Divers performed 1086 dives (mean 37, range: 3–100) during the observation period. Four divers (14 per cent) experienced AV during five dives (0.46 per cent), (one diver experienced AV two times). It was found that having an otitis media history or eustachian tube dysfunction determined with the nine-step inflation/deflation tympanometric test before diving, or difficulty in clearing ears during diving could be important risk factors for AV in sport SCUBA divers (p<.05). Divers with such findings seem to be more prone to AV and should pay rigorous attention to the precautions for prevention of AV.

Rhinocerebral mucormycosis is an uncommon, rapidly progressive, highly fatal sinus infection, usually occurring in immunocompromised hosts. We describe our clinical experience with nine such consecutive cases managed at our centre, with emphasis on identifying early diagnostic and prognostic features. Perinasal cellulitis/paraesthesia was the most frequent early clinical sign of disease, being evident in at least six cases. Periorbital oedema, mucopurulent rhinorrhoea and nasal crusting were the other early manifestations. Concurrent computed tomography (CT) scan at this initial stage however revealed only minimal mucosal thickening of the sinuses in all four cases wherein it was done. Intracranial extension as evident on CT was the only adverse prognostic sign (p<0.05). The present report highlights the importance of early diagnosis and prompt institution of antifungal chemotherapy in ensuring a favourable outcome in rhinocerebral mucormycosis. However, initial CT is frequently near-normal and biopsy time-consuming and often not feasible. To optimize early diagnosis therefore, the clinician should be highly alert to certain subtle clinical signs, in the appropriate setting of an immunocompromised patient.

A pilot study to assess the safety and efficacy of ’degloving’ of the inferior turbinate is described. This prospective study reports on the effectiveness of the technique in 37 patients with nasal obstruction due to inferior turbinate hypertrophy. Both objective and subjective measurements of nasal patency were made pre-operatively, and repeated at six weeks, six months and two years post-operatively using nasal inspiratory peak flow rates, saccharin clearance time and an end referenced visual analogue scale to record nasal symptoms.

There was a significant improvement in the peak inspiratory flow at six weeks (96.4 to 151.2 l/min) and at six months (148.4 l/min), which was sustained at two years (117.1 l/min, p<0.001). There was an overall improvement in patient satisfaction with nasal symptoms (23.4 to 76.7, 76.8 and 66.8 at six weeks, six months and two years, p<0.001) and a decrease in the sensation of nasal obstruction (71.9 to 21.5, 32.9 and 29.8, p<0.001), which was also sustained. Rhinorrhoea was reduced, and sense of smell increased across the group, but the improvements did not reach statistical significance. The results for postnasal drip and saccharin clearance did not show a significant change over the period of the study. There were no haemorrhagic complications in the group studied.

This pilot study demonstrates a new surgical technique for reduction of the inferior turbinates, that yields significant improvement in nasal obstruction, an acceptably low complication rate and is well tolerated by patients. A randomized controlled trial is being planned.

In this study the status of oxidant stress, vitamin A and angiotensin-converting enzyme (ACE) levels were evaluated in cases of laryngeal carcinoma patients from Northern India. In control subjects the levels of malondialdehyde (MDA), vitamin A and ACE were 0.23 ± 0.07 nmole/ml, 2515 ± 84 IU, and 1.4 ± 0.8 U/ml respectively. Thirty laryngeal cancer patients were divided into three groups according to the TNM classification (American Joint Committee on Cancers). In laryngeal cancer patients according to tumour size, MDA and ACE levels increased to 0.32 ± 0.04 nmole/ml and 4.7 ± 0.5 U/ml respectively and the effect was statistically significant (p<0.01). The correlation coefficient between different subgroups was also highly significant (r =0.96, p<0.01). However, serum vitamin A levels decreased to 621 ± 20 IU and the effect was statistically significant (p<0.01). In another two groups of laryngeal cancer patients, a similar pattern of various markers was obtained. Thirty patients with laryngeal carcinoma were divided into four different groups according to nodal involvement and it was observed that in laryngeal cancer patients with no nodal involvement, ACE levels were low 3.6 ± 1.4 U/ml while patients with maximum nodal involvement had the highest levels of ACE 7.1 ± 0.18 U/ml. The correlation coefficient between different groups is highly statistically significant (r = 0.95, p<0.01). In patients with laryngeal cancer the serum MDA and vitamin A levels correlation coefficient between different groups was not significant. It is thus concluded that serum ACE might be a specific test marker for laryngeal cancer disease burden. The use of this marker enzyme for therapeutics is being planned.

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.

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.

Nasogastric intubation is often difficult in patients with upper aero-digestive tract tumours. We present a new method for replacing obstructed fine-bore nasogastric tubes. This method eliminates the need for specialized equipment and skills, minimizes the risk of tracheal intubation and oesophageal trauma, and is better tolerated by patients.

Mucous membrane pemphigoid (MMP) is a sub-epithelial blistering disease that primarily involves mucosal surfaces but may also involve the skin. Clinically, it appears as vesiculobullous lesions of the oral cavity and eyes, but other tissues such as the nasopharyngeal and laryngeal mucosa can also be affected. Ultimately, scarring and airway stenosis may occur. The condition should be managed by a multidisciplinary team led by a dermatologist. Immunosuppressive therapy forms the mainstay of treatment, with surgery having both a diagnostic role and a use in the treatment of complications such as airway obstruction. There must be a low threshold of suspicion for laryngeal involvement in this group of patients, so that prompt action can be taken. Once laryngeal stenosis has occurred repeated endoscopic laser excision of scar tissue can be used to maintain an adequate airway. Adjuvant use of mitomycin-C can be used beneficially in the treatment of laryngeal complications of MMP.

Solitary fibrous tumours are rare neoplasms, which occur most frequently during adulthood at the level of the pleura. Recently, these tumours have been demonstrated in extraserosal sites such as the nasal cavity. A case of a solitary fibrous tumour arising at the level of the ethmoid and presenting in a 54-year-old woman, is reported. The tumour was removed using an endonasal endoscopic approach that permitted the monobloc excision of the lesion. The patient is without evidence of disease 18 months after surgery.

This paper describes the use of endoscopic visualization in curettage of orbital cholesterol granuloma (OCG). Two males aged 54 and 50 years presented with orbitofrontal cholesterol granulomas arising in the superolateral frontal bone and abutting the dura. The granulomas were approached via a superior eyelid crease incision and a 70 degree rigid endoscope was used to visualize curettage of the granuloma from the inner surface of the frontal bone and the dura. Both patients made an uncomplicated recovery and there was no recurrence at eight months and two years follow up.

Percutaneous endoscopic curettage is an alternative to blind curettage, lateral orbitotomy or frontal craniotomy for OCG.

Hypoplasia or absence of the epiglottis in an adult is a rarely reported congenital anomaly that usually occurs in association with congenital anomalies of other organ systems. Most epiglottic anomalies usually present in infancy and early childhood with respiratory and feeding problems and the affected individual dies shortly after birth due to multiple congenital anomalies. We present a case of congenital absence of the epiglottis and false vocal folds with hypoplastic maxillae in an adult.

Upper aerodigestive tract injury after endotracheal intubation is a rare but serious complication. The case of a 57-year-old female, who developed extensive neck and pneumomediastinum following a knee arthroscopy under general anaesthesia, is presented. Possible mechanisms of injury and management options are discussed.

It is well known how difficult it is to localize a foreign body in the sub-mucosal tissues. This is a report of a male who swallowed a metal wire which lodged in the pharyngeal sub-mucosal tissue. The foreign body was localized using an image intensifier and removed successfully.

Sialolithiasis is a major cause of salivary gland dysfunction. The submandibular gland is the most common site followed by the parotid gland. The sublingual gland and minor glands are very rare sites for stone formation. This paper describes a case of multiple sialoliths arising in the sublingual gland. They presented on the right floor of the mouth. The sublingual gland and sialoliths were completely removed with careful preservation of the lingual nerve and Wharton’s duct. This was an uncommon sialolithiasis of the sublingual gland in a 14-year-old female.

Pleomorphic adenoma arising from the external auditory canal is a very rare neoplasm, and there has been no report on magnetic resonance (MR) imaging of pleomorphic adenoma of the external auditory canal. We report here a case of 65-year-old male with this tumour, measuring 12 mm in a diameter. Histopathology was confirmed from the specimen obtained at the surgical excision. MR revealed that the tumour had a well-defined margin showing hypointensity on T1-weighted images and hyperintensity on T2-weighted images relative to the parotid gland. The tumour was well enhanced by contrast material. No invasion to the surrounding tissue was observed. These MR findings were compatible with pleomorphic adenoma of the salivary gland origin. In treating pleomorphic adenoma of the external auditory canal, complete surgical excision is essential for the prevention of recurrence. It can be concluded that MR imaging is helpful for making a differential diagnosis of external auditory canal tumours and selection of adequate treatment.