Secondary tracheoesophageal puncture is sometimes difficult and has a higher complication rate. In the irradiated neck, where neck extension is difficult, the traditional tracheoesophageal puncture method of insertion with a rigid endoscope is not possible. We describe a simple, safe and effective alternative method of tracheoesophageal puncture using curved forceps (Kocher's curved intestinal clamp forceps or Mixter forceps).

The procedure is performed under local or general anaesthesia with equal ease. Maximum neck extension is achieved. The curved intestinal forceps are passed through the mouth into the oesophageal lumen. The instrument tip can easily be seen or felt at the posterior wall of the tracheostoma. A small incision is made in the mucosa to allow the forceps tip to emerge, and a guide wire is passed through this incision out of the mouth. The prosthesis can be guided over the guide wire, in retrograde fashion, to fit the puncture hole.

Secondary tracheoesophageal puncture was performed in five cases with severe neck fibrosis. In all cases, valve insertion was easily achieved after secondary tracheoesophageal puncture, without any peri-operative complications.

This is a safe, simple and effective method for secondary tracheoesophageal puncture. It can be performed easily in any setting and is not associated with any complications.

To evaluate the literature and to compare published data on age-standardised incidence rates of nasopharyngeal carcinoma in Chinese people living in and outside China.

Systematic review of incidence rate studies and statistical incidence data concerning nasopharyngeal carcinoma in Chinese populations from 1960 to 2008.

Sixteen papers were identified from the PubMed, Embase and Scopus electronic databases and from a hand search of the reference lists of the retrieved papers. Further searches for raw data on age-specific and age-standardised incidence rates of nasopharyngeal carcinoma were conducted. Textbooks on relevant subjects were referred to for background information. A total of 19 papers met the inclusion criteria.

Seven studies included raw data on age-specific and age-standardised incidence rates of nasopharyngeal carcinoma in Chinese people. Twelve other studies reported on changes in the incidence of nasopharyngeal carcinoma in Chinese populations in selected countries or regions. Studies on age-specific and age-standardised rates obtained data from individual registries. Studies on incidence rates obtained data from hospital records, cancer notifications (from all sections of the medical profession), pathology records and death certificates. The results showed a decline in age-standardised incidence rates of nasopharyngeal carcinoma in Chinese immigrant populations, compared with Chinese people in China. There was also a trend towards decreasing incidence the further the population had immigrated. Thus, the incidence of nasopharyngeal carcinoma in Singaporean Chinese was higher than that in Hawaiian Chinese, and that in Hawaiian Chinese was higher than that in Californian Chinese.

This review found a decreasing trend in the incidence of nasopharyngeal carcinoma in Chinese migrants living in countries with a low risk of the disease.

Ossicular chain damage from chronic ear disease is a significant problem in the Australian population. The ideal ossicular chain reconstruction prosthesis has yet to be defined. This paper examines, for the first time, the use of a titanium prosthesis for ossicular chain reconstruction in Australian patients.

Retrospective chart review.

All patients undergoing ossicular chain reconstruction with a titanium prosthesis between 1 February 2002 and 31 March 2007.

Results showed a low complication rate, with only one extrusion out of 55 cases (1.8 per cent). Successful rehabilitation of conductive hearing loss (i.e. to ≤20 dB air–bone gap) was obtained in 85 per cent of the partial ossicular chain reconstruction group and 77 per cent of the total ossicular chain reconstruction group. Pure tone thresholds improved by an average 18 dB in the partial reconstruction group and 25 dB in the total reconstruction group.

Titanium is an ideal material for ossicular chain reconstruction due to its ease of insertion, low rate of extrusion and good functional results.

Despite advances in imaging and other diagnostic tests, it is often impossible to establish with confidence a pre-operative diagnosis in a patient with a conductive hearing loss.

We studied a series of 340 exploratory tympanotomies for conductive hearing loss carried out by a single surgeon.

The most common operative diagnosis was otosclerosis (n = 164, 48.2 per cent). Ossicular discontinuity was found more commonly than previously reported (n = 103, 30.3 per cent). A small but significant number of patients were found to have cholesteatoma (n = 7.2 per cent).

This information is of value when discussing potential findings at surgery for conductive hearing loss. While otosclerosis is the commonest finding in such cases, a significant number of patients have defects of the ossicular chain.

Hearing sensitivity usually diminishes with noise exposure. In the present study, we examined the effect of 93 dB(A) wide band noise on cochlear micromechanical sensitivity in awake guinea pigs.

Animals were randomly assigned to groups receiving either single or repeated noise exposure. Distortion product otoacoustic emission amplitudes were recorded before, during and after noise exposure.

Ninety-three decibel(A) wide band noise reduced the distortion product otoacoustic emission amplitudes at all tested frequencies. The distortion product otoacoustic emission amplitudes for higher frequencies showed a permanent reduction, whereas those for lower frequencies showed a temporary reduction. Distortion product otoacoustic emission amplitudes for middle frequencies showed prolonged enhancement after repeated noise exposure.

Our results suggest that (1) it is likely that there are intermediate stages between permanent threshold shift and temporary threshold shift, and (2) long-term enhancement of distortion product otoacoustic emission amplitudes may be an indication of tinnitus generation.

To collect and analyse data from the published literature concerning the rare condition necrotising otitis externa, in order to formulate a prognostic scoring model based on signs and symptoms.

Retrospective data collection from published literature, and binary logistic regression analysis of the effect on outcome of identified signs and symptoms.

Six factors were identified as prognostic of a poorer outcome, including facial nerve involvement, additional cranial nerve involvement, non-cranial nerve neurological involvement, extensive granulations (or oedema) in the external auditory canal, bilateral symptoms and aspergillus species as the causative organism. A four-point scoring model based on these findings is presented.

A novel, systematic method of data analysis was utilised to construct a prognostic scoring model for necrotising otitis externa. This will better equip clinicians to treat this potentially fatal condition.

Interferon-γ has been reported to have an immunoregulatory role in otitis media with effusion. However, such a role remains to be determined in acute suppurative otitis media.

To determine the levels of interferon-γ in middle-ear secretion in children with acute suppurative otitis media, and to determine the significance of interferon-γ to the nature of otorrhoea and the outcome of otitis media.

Prospective, longitudinal follow up of patients selected from community and tertiary health centres.

We selected children with acute suppurative otitis media, diagnosed as otorrhoea of less than three months' duration. Middle-ear secretions were collected by pipetting and stored at −80°C. Interferon-γ was assayed using enzyme-linked immunosorbent assay. The patients were treated and followed up for nine to 12 months, to separate those with resolved acute suppurative otitis media from those with chronic suppurative otitis media.

The study initially included 358 cases of acute suppurative otitis media. Nine-month follow up was achieved in 304 patients (85 per cent). Of these patients, acute suppurative otitis media resolved in 187 (61 per cent), while chronic suppurative otitis media was evident in 117 (39 per cent). The children with completed follow up comprised 173 boys and 131 girls, aged between four months and nine years (mean age 6.6 years; standard deviation 1.32). These children had purulent otorrhoea in 171 cases (56 per cent) and mucoid otorrhoea in 133 cases (44 per cent). The children's middle-ear secretion interferon-γ concentrations ranged from 12 to 126 pg/ml. The mean middle-ear secretion interferon-γ concentration was 27.2 pg/ml (standard deviation 8.8) in patients whose acute suppurative otitis media resolved, and 73.1 pg/ml (standard deviation 9.5) in those progressing to chronic suppurative otitis media. In children with purulent otitis media, the mean middle-ear secretion interferon-γ concentration was 43.5 pg/ml (standard deviation 15.6); in those with mucoid otitis media, it was 74.3 pg/ml (standard deviation 19.1). Univariate analysis revealed significant differences in middle-ear secretion interferon-γ concentration, comparing resolved acute suppurative otitis media and chronic suppurative otitis media cases (p = 0.00), and comparing purulent and mucoid otitis media cases (p = 0.00). Pearson correlation testing revealed significant inverse correlation between interferon-γ concentration and middle-ear secretion immunoglobulin G concentration (p = 0.01), immunoglobulin E concentration (p = 0.03) and immunoglobulin A concentration (p = 0.00).

A high concentration of interferon-γ in middle-ear secretions promotes chronicity of suppurative otitis media. Further research in this area may lead to the development of agents which assist the control of suppurative otitis media chronicity.

We evaluated the results of mobile, one stage, bilateral ear surgery conducted in Greenland, where chronic otitis media with and without suppuration is prevalent. The study aimed to increase the number of operations conducted and to reduce the cost of ear surgery in remote areas.

The study was longitudinal and prospective, with a two-year follow up. Seventeen East Greenlandic patients with bilateral chronic suppurative otitis media or chronic otitis media were selected. Their median age was 16 years; 53 per cent were female and 47 per cent male. Hearing was assessed using median air conduction pure tone average gain, and the ‘take rate’ (i.e. the percentage of total ears with a closed perforation) was evaluated.

All patients attended for follow up. Eighty-two per cent had at least one perforation closed, and the overall take rate was 65 per cent of the 34 ears. The median air conduction pure tone average gain after two years was 18 dB and 13 dB for the right and left ears, respectively. Fourteen patients (82 per cent) obtained an air conduction pure tone average hearing level of ≤25 dB in at least one ear. In total, 71 per cent of the patients were satisfied. There were no hearing hazards.

The results of mobile, one stage, bilateral ear surgery conducted in Greenland for long-lasting chronic suppurative otitis media and chronic otitis media were acceptable and safe, and more ears underwent surgery at reduced cost compared with unilateral ear surgery.

To evaluate the results of one-stage surgical repair of the meatal skin defect in patients with long-lasting osteoradionecrosis of the outer ear canal, using a postauricular, inferiorly pedicled skin flap. All patients were also treated with hyperbaric oxygen both pre- and post-operatively.

A prospective study evaluating the results of a one-stage surgical procedure to repair the meatal skin defect in five patients with osteoradionecrosis of the outer ear canal. All patients were treated with hyperbaric oxygen both pre- and post-operatively.

In four of the five patients, intact canal skin was achieved after surgery and hyperbaric oxygen therapy. One patient needed a second operation to cover a small remaining area of bare bone. In one patient, wound healing was unsatisfactory and an area of bare bone remained.

In cases of osteoradionecrosis of the outer ear canal, the skin defect can be repaired with an inferiorly pedicled skin flap. Although not yet scientifically proven, the peri-operative application of hyperbaric oxygen may be of additional value to improve wound healing in areas of compromised tissue.

The aim of this study was to describe the results of treatment in patients with ethmoid sinus carcinoma.

We performed a retrospective study of 34 patients with carcinoma of the ethmoid sinus, and collected the following data: age, sex, employment, tobacco and alcohol consumption, tumour-node-metastasis stage, treatment, and survival.

The mean patient age was 64 years. Seventy-six per cent of patients were men and 24 per cent women. Squamous cell carcinoma was the most frequent histological tumour type (44 per cent). Eleven patients were classified as T2, six as T3, six as T4a and 11 as T4b. Two patients (6 per cent) had nodal metastasis at the time of diagnosis. The anterior skull base was involved in 17 patients (50 per cent) and the anterior orbital contents were affected in seven patients (21 per cent). The five-year actuarial observed survival rate for all patients was 44 per cent.

Combined treatment with surgery and post-operative radiotherapy permitted good local control in patients with ethmoid sinus carcinoma. We do not recommend prophylactic neck treatment for ethmoid sinus carcinoma.

In vivo laser scanning confocal microscopy is a relatively new, non-invasive method for assessment of oral cavity epithelia. The penetration depth of approximately 200–400 µm allows visualisation of fungiform papillae and their taste buds.

This paper describes the technique of in vivo volumetry of human taste buds. Confocal laser scanning microscopy used a diode laser at 670 nm for illumination. Digital laser scanning confocal microscopy equipment consisted of the Heidelberg Retina Tomograph HRTII and the Rostock Cornea Module. Volume scans of fungiform papillae were used for three-dimensional reconstruction of the taste bud.

This technique supplied information on taste bud structure and enabled measurement and calculation of taste bud volume. Volumetric data from a 23-year-old man over a nine-day period showed only a small deviation in values. After three to four weeks, phenomenological changes in taste bud structures were found (i.e. a significant increase in volume, followed by disappearance of the taste bud and appearance of a new taste bud).

The data obtained indicate the potential application of this non-invasive imaging modality: to evaluate variation of taste bud volume in human fungiform papillae with ageing; to study the effects of chorda tympani nerve transection on taste bud volume; and to demonstrate recovery of taste buds in patients with a severed chorda tympani nerve who show recovery of gustatory sensibility after surgery.

Vocal cysts with fold atrophy often result in more severe glottal incompetence than vocal cysts along during phonation. Although total excision or marsupialisation are reliable treatments for vocal fold cysts, any post-operative vocal deficit with significant glottal gap will need further treatment. This study aimed to evaluate the efficacy of combined treatment consisting of marsupialisation of the cyst immediately followed by strap muscle transposition laryngoplasty.

Under direct laryngomicroscopy, microscissors were used to make a disc-shaped incision encircling the equator of the cyst. After marsupialisation of the cyst, a simultaneous medialisation laryngoplasty with strap muscle transposition was performed.

Seven patients with vocal cysts and marked vocal fold atrophy were included in the study. After surgery, subjective improvement in voice quality was reported by all patients. Patients' glottal incompetence and vocal performance were markedly improved.

Marsupialisation is a simple and effective surgical technique for vocal fold cysts. For cases of vocal cysts with marked vocal fold atrophy, marsupialisation followed by medialisation laryngoplasty with strap muscle transposition may be considered.

Follow up of patients with differentiated thyroid cancer is based upon anatomical imaging, thyroglobulin assay and functional imaging in the form of iodine uptake scanning. A significant cohort of such patients have rising thyroglobulin levels but negative iodine scans. In this group, 18fluoro-2-deoxyglucose positron emission tomography scans have been commonly employed. The aim of this study was to assess the usefulness of such investigation.

The sensitivity of 18fluoro-2-deoxyglucose positron emission tomography for detecting recurrence of differentiated thyroid cancer was calculated from a retrospective review of scan results from patients with iodine scan negative recurrence.

Eighteen patients with rising thyroglobulin levels underwent 18fluoro-2-deoxyglucose positron emission tomography scanning. Fourteen patients had negative (and four equivocal) whole body iodine scintigraphy scans. Of these 14, six patients had a positive 18fluoro-2-deoxyglucose positron emission tomography scan, giving a sensitivity of 42.9 per cent.

When assessed in the clinical setting and restricted to patients with negative iodine scans, the sensitivity of 18fluoro-2-deoxyglucose positron emission tomography was found to be lower than in previous case series.

Sulphur mustard is a chemical warfare agent which was used against Iranian combatants and civilians between 1983 and 1988. The purpose of this study was to document the delayed toxic effects of sulphur mustard in Iranian veterans, focussing on head and neck complications.

This was a two-year, prospective, descriptive study of 43 male Iranian veterans aged 34 to 48 years (mean 41.8 years) who were moderately disabled or worse due to sulphur mustard poisoning. Investigations were performed with consent, including haematological, biochemical and immunological tests, spirometry, chest X-ray, high resolution computed tomography of the lungs, and skin biopsies. Further investigations and interventions were performed as clinically indicated.

The most affected sites were the lungs (95 per cent), peripheral nerves (77 per cent), skin (73 per cent), eyes (68 per cent), and head and neck (16.2 per cent). Of seven patients with mostly head and neck complications, four had a skin disorder (hyperpigmentation in all four, an erythematous, papular rash in two, and dry skin in one). Two patients had thyroid cancer (undifferentiated thyroid carcinoma in one and papillary carcinoma of a thyroglossal cyst in the other, 12 and 14 years after sulphur mustard exposure, respectively). One patient had nasopharyngeal carcinoma, 12 years after sulphur mustard exposure.

Carcinomas of the thyroid and nasopharynx in three patients with sulphur mustard exposure are reported for the first time.

‘High stakes’ postgraduate medical examinations should conform to current educational standards. In the UK and Ireland, national assessments in surgery are devised and managed through the examination structure of the Royal Colleges of Surgeons. Their efforts are not reported in the medical education literature. In the current paper, we aim to clarify this process.

To replace the clinical section of the Diploma of Otorhinolaryngology with an Objective, Structured, Clinical Examination, and to set the level of the assessment at one year of postgraduate training in the specialty.

After ‘blueprinting’ against the whole curriculum, an Objective, Structured, Clinical Examination comprising 25 stations was divided into six clinical stations and 19 other stations exploring written case histories, instruments, test results, written communication skills and interpretation skills. The pass mark was set using a modified borderline method and other methods, and statistical analysis of the results was performed.

The results of nine examinations between May 2004 and May 2008 are presented. The pass mark varied between 68 and 82 per cent. Internal consistency was good, with a Cronbach's α value of 0.99 for all examinations and split-half statistics varying from 0.96 to 0.99. Different standard settings gave similar pass marks.

We have developed a summative, Objective, Structured, Clinical Examination for doctors training in otorhinolaryngology, reported herein. The objectives and standards of setting a high quality assessment were met.

To establish the safety and effectiveness of nurse-led triage of otolaryngology out-patient referrals.

One hundred consecutive general practitioner referrals were reviewed by two consultants, two specialist registrars, two foundation year two senior house officers and two otolaryngology nurses. One of the nurses had received triage training. All referrals were triaged as ‘urgent’, ‘soon’ or ‘routine’ by each rater.

The triage-trained nurse's results demonstrated good agreement with those of the senior consultant (80 per cent). This agreement was similar to that with the other consultant (77 per cent) and the specialist registrars (79 and 82 per cent). Weighted κ statistics (correcting for chance agreement) showed that the triage-trained nurse had the second closest agreement to the senior consultant (0.66). After the actual out-patient appointments, retrospective review of the patients' case notes revealed that none had been triaged inappropriately by the trained nurse, and no urgent cases had been missed.

Triage of out-patient referrals by trained ENT nurses is safe and effective, and is an acceptable alternative to traditional consultant vetting of referrals.

Branchial cleft anomalies are well described, with the second arch anomaly being the commonest. Following surgical excision, recurrence occurs in 2 to 22 per cent of cases, and is believed to be due largely to incomplete resection. This report aims to describe a simple surgical technique for treatment of second branchial cleft sinus in the older paediatric age group and adults.

An 11-year-old girl underwent surgical excision of a second branchial sinus. Prior to surgery, she was assessed by means of an imaging sonogram, and by direct methylene blue dye injection into the sinus on the operating table, followed by insertion of a metallic probe. Dissection was of the ‘step ladder’ incision type, but the incision was completed via an oropharyngeal approach. Histological examination of the lesion after excision established the diagnosis. No recurrence had been observed at the time of writing.

Although they are congenital lesions, second branchial cleft abnormalities usually present in the older paediatric age group or even in adulthood. In the case reported, a simple combined approach ensured completeness of resection.