The surgical management of inferior turbinate enlargement is controversial. Submucosal electrosurgical techniques for turbinate reduction include conventional diathermy, radiofrequency tissue reduction and coblation. All electrosurgical techniques use radiofrequency electricity to damage turbinate tissue but differ in the control and delivery of energy. This review will examine the history of submucosal electrosurgery and clarify the various techniques. This review will also examine the evidence for the efficacy and safety of electrosurgery for the treatment of nasal turbinate enlargement, and will make a case that no progress will be made in clinical trials on the safety and efficacy unless there is standardisation of equipment and techniques in nasal electrosurgery.

The use of intranasal steroids by otolaryngologists in the treatment of patients with infective rhinosinusitis and after endonasal surgery, particularly endoscopic sinus surgery, is unlicensed, as stated in the British National Formulary and in the manufacturers' leaflets supplied with nasal steroid medications. However, despite this, nasal steroids continue to be prescribed in these circumstances. Debate continues as to the exact role of intranasal steroids in sinonasal infection and after sinonasal surgery and whether their use in these circumstances should still be unlicensed.

This article reviews the current medical literature regarding this topic and aims to clarify whether intranasal steroid usage in these circumstances should be recommended.

Objectives: Assessment of the histopathologic effect of transtympanic and intramuscular administration of dexamethasone in an in vivo experimental animal model of middle-ear mucosal inflammation.

Methods: Fifty healthy rabbits weighting 1500–1800 g were randomly divided in three groups. In 10 animals (control group), 0.5 ml of a 20 mg/ml histamine solution was injected transtympanically. In 20 rabbits (group A), histamine challenge followed a three day intramuscular pretreatment with dexamethasone at 1 mg/kg per day. In 20 rabbits (group B), histamine challenge followed pretreatment with dexamethasone via a transtympanic route (0.3 ml, 1.2 mg dexamethasone). Middle-ear mucosa was obtained for histopathology 30 minutes after histamine administration. The following parameters were assessed: inflammation, acute inflammatory component, presence of eosinophils, inflammatory activity and fibrosis.

Results: Oedema, vascular dilatation and congestion, inflammation, the presence of an acute (polymorphonuclear) inflammatory component, the presence of eosinophils, and inflammatory activity were found to be of a lesser grade in the mucosae of group B. All differences were found to be statistically highly significant (p<0.01) using the Mann–Whitney test.

Conclusion: Our findings validate the transtympanic route of dexamethasone administration in counteracting histamine effects.

Objectives: We aimed to identify the frequency with which the following conditions were present as a second disability in cochlear-implanted, prelingually deaf persons: mild and moderate mental retardation; learning disability; attention deficit/hyperactivity disorder; cerebral palsy; congenital blindness; and autism. We also aimed to document the development of auditory perception in patients having one of these additional disabilities.

Study design: A retrospective study was designed to pursue the above aims.

Methods: We examined the records of 398 cochlear-implanted, prelingually deaf patients who had received a cochlear implant at least one year previously. Patients were selected who showed a delay in motor, cognitive or emotional development. The selected cases were referred for psychological evaluation in order to identify patients with additional disabilities. We then compared these patients' auditory perception prior to and one year following cochlear implantation.

Results: A total of 60 (15 per cent) cochlear-implanted, prelingually deaf patients were diagnosed with additional disabilities. These were classified as: mild mental retardation in eight cases (13.33 per cent); moderate mental retardation in five (8.33 per cent); learning disability in 20 (33.33 per cent); attention deficit/hyperactivity disorder in 15 (25 per cent); cerebral palsy in five (8.33); congenital blindness in three (5 per cent); and autism in four (6.66 per cent). All patients showed significant development in speech perception, except for autistic and congenitally deaf-blind patients.

Conclusion: Although cochlear implantation is not contraindicated in prelingually deaf persons with additional disabilities, congenitally deaf-blind and autistic patients showed limited development in auditory perception as a main outcome of cochlear implantation. These patients require unique rehabilitation in order to achieve more auditory development.

Objective: To formulate an alternative strategy for universal infants hearing screening in an Indian tertiary referral hospital with a high delivery rate, which could be extended to similar situations in other developing countries. The system should be able to diagnose, in a timely fashion, all infants with severe and profound hearing losses.

Methods: One thousand newborn were randomly selected. All underwent testing with transient evoked oto-acoustic emissions (TEOAE) in the first 48 hours of life. All TEOAE failures were followed up and repeat tests were performed at three weeks, three months and six months of age. Infants with acceptable TEOAE results at any of the four ages were discharged from the study. Infants with unacceptable TEOAE results at all the four ages underwent brainstem evoked response audiometry and oto-endoscopy. The ‘pass rate’ for TEOAE testing was calculated for all four ages. The time taken to perform TEOAE and brainstem evoked response audiometry was recorded for all subjects. These recordings were statistically analysed to find the most suitable strategy for universal hearing screening in our hospital.

Results: The pass rate for TEOAE was 79.0 per cent at ≤48 hours, 85.0 per cent at three weeks, 97.0 per cent at three months and 98.0 per cent at six months. The average time taken to perform the test was 12 minutes for TEOAE and 27 minutes for brainstem evoked response audiometry. Obstructed and collapsed external auditory canals were the two factors that significantly affected the specificity of TEOAE in infants ≤48 hours old.

Conclusion: The concept of screening all neonates within the first 48 hours of life is impractical because the specificity of TEOAE is lowest at that age. Many false positive results are generated, such that a larger number must undergo brainstem evoked response audiometry, wasting time and resources. This can easily be avoided by delaying TEOAE screening until three months of age, when it has a substantially lower false positive outcome. We expect that implementation of this alternative strategy in our hospital will maximise the benefits of such a programme.

A growing body of literature suggests that cytokines play an important part in the pathogenesis of chronic nasal sinusitis. However, the mechanism by which the expression of cytokines in chronic nasal sinusitis is upregulated has not been well documented. The present study investigated the role of nuclear factor-kappa B (NF-κB) activation in upregulating the expression of interleukin-5, -6 and -8 (IL-5, IL-6 and IL-8). We titrated the levels of IL-5, IL-6 and IL-8 in nasal mucosa in 52 cases of chronic nasal sinusitis and 12 normal subjects using enzyme-linked immunosorbent assay. According to whether allergic rhinitis was associated or not, we subdivided the patients into the AR group (with allergic rhinitis) and the NAR group (without allergic rhinitis). Semi-quantitative reverse transcription-polymerase chain reaction and immunohistochemical staining were used to evaluate expression and activation of NF-κB P50 and P65 subunits in nasal mucosa. The correlation between activities of P50 and P65 and cytokines expression was analysed. Our results showed that IL-5, IL-6 and IL-8 in both the AR and NAR groups were strikingly elevated in comparison with the control group (all p < 0.01 for AR group; p < 0.05, 0.05, 0.01, respectively, for NAR group); and they were even higher in the AR group than those in the NAR group (p < 0.01, 0.05, 0.01, respectively). P50 and P65 mRNA levels in both AR and NAR groups were markedly greater than those in the control group (all p < 0.01); and the AR group had further higher levels as compared with the NAR group (both p < 0.05). Immunohistochemical study revealed that nucleus-positive rates of P50 and P65 in both AR and NAR groups were significantly higher than those of the control group (all p < 0.01), and they were much greater in the AR group in comparison with the NAR group (all p < 0.01). Pearson correlation analysis demonstrated that P50 and P65 nucleus-positive rates were closely correlated with IL-6 and IL-8 levels, but not IL-5, with a correlation coefficient of 0.49 for P50 and IL-6, 0.54 for P50 and IL-8, 0.61 for P65 and IL-6, and 0.66 for P65 and IL-8 (all p < 0.01). In conclusion, upregulated expression and activation of NF-κB P50 and P65 might be one of the mechanisms for induction of IL-6 and IL-8 expression in chronic nasal sinusitis. Association of allergic rhinitis with chronic nasal sinusitis further enhanced NF-κB activity, and subsequently lead to even stronger expression of IL-6 and IL-8. IL-5 expression appeared to be independent of NF-κB pathway in chronic nasal sinusitis.

The sino-nasal assessment questionnaire is a system used for scoring the symptoms of chronic rhinosinusitis. However, the range of scores for this questionnaire in the healthy adult population is unknown. We aimed to establish this by recruiting 100 healthy volunteers and comparing their sino-nasal assessment questionnaire scores with those of 100 individuals who had undergone sinus surgery for rhinosinusitis. The difference in mean scores in the symptomatic group (44.62) and the asymptomatic group (8.46) was statistically significant. However, there was substantial overlap between the scores of the two groups. Factors such as age, gender and smoking did not have a statistically significant impact on the eventual score in the asymptomatic group. We believe that symptom scores can only be used effectively when the range in the asymptomatic population is known. This is so that disease severity can be gauged in the context of the normal population and post-operative improvements can be forecast.

Design: a cross-sectional study.

Participants: One hundred and ninety-nine patients with Wegener's granulomatosis belonging to a patient self-help group.

Main outcome measures: Mode of initial presentation; diagnosis timescales and delay; rhinologic involvement; and treatment.

Results: Sixty-three per cent of patients initially presented with ENT-related symptoms. Ninety-two per cent faced a delay in their diagnosis of more than one month, a pattern which has not improved over the last few decades and which compares unfavourably with North American figures. Rhinologic and otologic symptoms are a common occurrence in up to 85 and 50 per cent of Wegener's granulomatosis patients, respectively, attracting varying degrees of targeted treatment.

Conclusions: As sinonasal and other ENT symptoms are so common at the presentation of Wegener's granulomatosis, it is clear that the otolaryngologist has an important role in its diagnosis and treatment. There are long delays in the diagnosis and possible under-treatment of the ENT symptoms of this condition, highlighting the need for greater awareness, particularly in the ENT community.

The management of paediatric airway emergencies is part of ENT practice. The most common conditions are acute viral laryngotracheobronchitis (croup), acute epiglottitis and bacterial tracheitis. Management of these conditions is significantly different and accurate diagnosis is crucial. We performed a retrospective analysis of all acute airway admissions to the paediatric intensive care unit (PICU) at the Royal Belfast Hospital for Sick Children from 1990 to 2003. The results showed a gradual decrease in the number of admissions due to croup. Acute epiglottitis admissions decreased markedly after 1992 but rose again in 2000, with a peak in 2002. Bacterial tracheitis is now the most common paediatric airway emergency requiring PICU admission and its incidence has been steadily increasing since 1990, peaking in 2003. The total number of admissions showed little change over the 14-year period audited. The significant shift in the nature of these conditions and these findings confirm the ongoing requirement for caution in dealing with a suspected airway emergency.

Problem: To overcome difficulties in complicated tracheotomies through the use of a T-incision.

Study design: Retrospective.

Methods: A T-shaped incision allows the wound edges to retract aside spontaneously, without the use of retractors. Four hundred and twelve patients were retrospectively evaluated; 203 received traditional tracheotomy incisions and 209 received a T-incision.

Results: Complication rates were similar for the two groups: 3 per cent in the traditional incision group and 4 per cent in the T-incision group (difference non-significant).

Conclusions: The T-incision enables good control of bleeding and better exposure of the trachea. This incision was developed for use in difficult cases, such as patients with a short or thick neck, and complicated needle dilatation procedures. The T-incision is quick and suitable for a solo surgeon. Its cosmetic results are acceptable, and it has the same low complication rate as traditional incisions.

Aim: To evaluate the impact of positive sleep nasendoscopy, with simultaneous mandibular advancement, on the outcome of mandibular advancement splint therapy in 120 subjects with sleep-related breathing disorders.

Methodology: Overnight polysomnography and sleep nasendoscopy were performed prior to splint therapy. Follow-up sleep studies, with the appliance in situ, were undertaken for those patients with obstructive sleep apnoea. Subjective outcome measures assessed daytime sleepiness and snoring.

Results: One hundred and seven (89 per cent) subjects completed the study. Follow-up sleep studies confirmed the efficacy of treatment, with patients showing a mean reduction in apnoea/hypopnoea index (from 18.9 to 4.9, p<0.001), Epworth sleepiness scale scores (from 11 to seven, p<0.001) and partner-recorded snoring scores (from 14 to eight, p<0.001).

Conclusion: Sleep nasendoscopy, with concomitant mandibular advancement to mimic the treatment effect, could be of prognostic value in determining successful mandibular advancement splint therapy.

Background: Brushing cytology is a well established diagnostic procedure used by gynaecologists, physicians and surgeons to obtain representative samples from lesions. Our aim was to evaluate its reliability in ulcerative and tumour-like conditions arising in the skin of the head and neck.

Methods: Over 28 months, 86 patients with suspected cutaneous malignant lesions underwent a cytological examination with a cytobrush within the otolaryngology department.

Results: Cytological analysis identified 63 out of 64 histologically documented malignant tumours (60 primary basal cell and squamous cell carcinomas and three metastatic adenocarcinomas), and 21 out of 22 benign lesions. There was one false positive and one false negative result.

Conclusions: Brushing cytology of suspected cutaneous malignant lesions is a rapid and reliable diagnostic method which helps the clinician to decide on appropriate planning and treatment. The technique can be performed as an out-patient procedure, and smear preparation can be done in the laboratory, even at a peripheral hospital.

Background: Eponym lists in major sources can give an aura of legitimacy to discredited diagnoses, as exemplified by the case of Barré–Lieou syndrome, a ‘rare’ vestibular disorder.

Methods: A literature review for information on the posterior cervical syndrome of Barré–Lieou.

Results: Barré–Lieou syndrome includes very common symptoms – tinnitus, dizziness, and head or neck pain – attributed to ischaemia caused by cervical sympathetic nerve compression. Its original description brings together many unrelated disorders, and its causative mechanism has been discredited. However, it appears credulously in a number of eponym lists, and references to the syndrome are steadily increasing on the internet in general and on alternative medicine and legal profession websites in particular.

Conclusion: By inclusion in eponym lists, without a disclaimer, a syndrome can be given legitimacy before the general public. A syndrome, such as Barré–Lieou syndrome, that is useless to the medical profession can unfortunately prove to be very useful for litigants and disability claimants.

Chaperones are used in order to avoid misunderstandings that can lead to false accusations. Consultations and examinations may be a minefield especially if the doctors are accused of sexual misconduct. The allegations may have irreparable effects on their reputation and may lead to removal from the medical register and to criminal charges being brought. We present the results of a questionnaire from 85 patients, exploring patient experience in ENT out-patients particularly with respect to examination of the ear under the microscope. This procedure necessitates close contact between the patient and doctor for several minutes and there may be inadvertent contact with intimate areas on the patient. Up to 30 per cent of patients expressed a preference for a chaperone during the ENT consultation. There was noticeably a greater proportion of men than women patients stating a preference for a chaperone during the consultation. Interestingly, there was a strong positive correlation between the presence of friends/relatives and the preference for a chaperone. Patients should be given the freedom to choose for or against the presence of a chaperone in clinic consultations. The most commonly predicted scenario requiring a chaperone is with the male doctor and female patient. This study shows that based on patient feedback, this scenario, although common is not the exclusive area in which chaperones should be used.

The NHS Connecting for Health agency continues to implement the national programme for information technology within the National Health Service (NHS). In preparation, NHS employees are being encouraged to develop their information technology skills via the European computer driving licence training course.

A postal survey of British Association of Otorhinolaryngologists members was undertaken to evaluate their levels of information technology training, competency and knowledge. Three hundred and thirty-six surgeons responded.

Most respondents had received no formal information technology training. Only 3.9 per cent had taken the European computer driving licence course.

Most surgeons felt comfortable using word processing and presentation software but were less comfortable with other applications. Junior surgeons were more confident in all areas of information technology application than senior surgeons.

Seventy-two per cent of surgeons wanted more information technology training. Most felt that such training should be routine at undergraduate and postgraduate level.

With the national programme committed to improving information technology infrastructure within the NHS, more formal training should be provided to ensure a basic standard of information technology competency amongst ENT surgeons.

Lemierre's syndrome is a rare and sometimes life threatening condition that requires prompt management. A case is reported of a previously healthy young male with Lemierre's syndrome. He developed internal jugular vein and cavernous sinus thrombosis, metastatic abscesses in the temporal lobe and lungs, temporal lobe venous infarction and severe thrombocytopaenia. Discussed are aspects of clinical presentation, diagnosis and management issues.

We present the case of a 71-year-old man with anaplastic thyroid cancer. On presentation, his thyroid function was normal, but he subsequently developed sudden, rapid thyrotoxicosis. Thyrotoxicosis in anaplastic thyroid carcinoma is very rare, but in all previously reported cases the patient was thyrotoxic at presentation. Our case is unusual as our patient presented euthyroid, and thyrotoxicosis developed subsequently. We challenge current ideas regarding the biochemical pathophysiology of rapid thyrotoxicosis in anaplastic thyroid carcinoma and provide an alternative explanation.

Endoscopic endonasal surgery on a 36-year-old man was complicated by perforation of the right internal carotid artery. The immediate, substantial haemorrhage was controlled by packing the sphenoid sinus. Intra-arterial angiography of the right internal carotid artery showed small irregularities proximal to the ophthalmic artery. A follow-up examination two weeks later documented a large pseudoaneurysm in the initially irregular arterial segment, which was successfully treated by endovascular coiling.

This case report illustrates the need for angiographic follow-up examinations following traumatic intracranial vessel injury in order to identify late pseudoaneurysm development.