Madelung's disease is a benign disorder characterized by the presence of lipomata in the head and neck areas. It is disfiguring for the sufferer and is usually asymptomatic. Dysphagia and airway obstruction are rare presentations. Early surgical excision is recommended to exclude sinister pathology and to improve patient function. This is the first report (according to our literature search) of a patient who presented with dysphagia and obstructive sleep apnoea and in whom surgical intervention resulted in an improvement in both these symptoms.

This paper describes a new application for radiofrequency ablation in head and neck surgery. Two patients with extensive laryngeal papillomata were successfully treated using this technology. The technique is described in detail, highlighting the main benefits of this approach as compared with existing techniques. These advantages include limited damage to underlying tissues and a bloodless field.

The superior mediastinum contains a considerable number of lymph nodes. Although occasionally involved in head and neck cancer, there are not many reports of mediastinal dissection in the practice of head and neck surgery. We present a group of seven patients with head and neck tumours that underwent mediastinal dissection in our department. Three patients are alive and free of disease six months to three years after the operation, two are alive with disease four and five years after the procedure, and two patients died peri-operatively. According to reviewed current literature, direct invasion of cancer of the head and neck to the mediastinum or mediastinal lymph node involvement is uncommon. Yet, mediastinal dissection provides the only chance for cure in selected cases.

A styloid process (SP) cutter was developed and put into clinical use. The design of components of the ‘styloidectome’ was based on the principles of mechanics. The measurements of the individual parts were determined on the basis of morphological data of the oropharynx from 40 subjects undergoing tonsillectomy under general anaesthesia. Experiments showed that the instrument could be used to transect the SP and excise the amputated bones from the deep tissue space. We used the instrument for the resection of elongated SPs, via an oral approach, in seven in-patients (involving 10 SPs) under general anaesthesia and in two out-patients (involving three SPs) under local anaesthesia. The length of the resected SP ranged from 0.8 to 2.5 cm and the stump of the SP was smooth. The removal lasted only seconds and blood loss was minimal, without any complications. The styloidectome was reliable, easy to use and could be used for the resection of an elongated SP under general or local anaesthesia.

Potentially serious complications have been documented in patients undergoing upper airway surgery for obstructive sleep apnoea (OSA). Consensus is lacking regarding peri- and post-operative monitoring and identification of those patients likely to suffer post-operative complications.

This retrospective review of 118 patients treated and 152 surgical procedures undertaken, from January 1998 to December 2003, addresses this issue. The overall peri- and post-operative complication rate was 13.8 per cent, with one patient experiencing upper airway compromise, five patients experiencing post-operative oxygen desaturation within 150 minutes of extubation, six patients experiencing persistent hypertension and four patients suffering secondary haemorrhage. All patients were treated accordingly and recovered well, with no mortality. From these results, it is concluded that patients with severe OSA (apnoea–hypopnoea index > 60 and lowest oxygen saturation <80 per cent) are at higher risk of post-operative oxygen desaturation. Post-operative hypertension is more likely in patients with a prior history of hypertension. Routine post-operative admission to an intensive care unit for all OSA patients is unnecessary (including patients with severe OSA). However, all patients with OSA should be closely monitored in the post-anaesthesia care area for at least three hours after surgery; based on the outcome of this period and the clinical judgment of the clinician, the patient can then be observed overnight in either the high dependency unit or on a general ward. Patients with mild OSA may be admitted to the 23-hour ambulatory unit post-operatively. Use of continuous positive airway pressure in the immediate post-operative period can reduce the incidence of post-operative respiratory compromise and complications and is strongly recommended.

Cricotracheal separation (CTS) is an uncommon injury, with a high index of suspicion required to establish the diagnosis. Computerized tomography (CT) plays a role in diagnosis but cannot necessarily be relied upon. Bilateral recurrent laryngeal nerve (RLN) palsies are usually associated with this type of injury. We recently treated a patient with CTS in whom one RLN was intact from the time of the injury and the other nerve recovered within three months. Computed tomography was inconclusive.

Early open repair of the injury and frequent follow-up examinations led to successful decannulation after six weeks and excellent short-term voice and airway outcomes.

A detailed discussion of this unusual case is followed by a review of the current literature on CTS, with particular emphasis on significant management dilemmas and controversies.

Clinical suspicion remains more sensitive than investigations in diagnosing CTS. Permanent bilateral RLN palsies are not inevitable following these injuries.

Objectives: The tracheoesophageal puncture (TEP) technique and the insertion of its associated voice prostheses may give rise to adverse events. We present our experience with this technique, paying special attention to the incidence and management of these adverse events.

Study design: A retrospective clinical analysis was undertaken.

Methods: Seventy-five laryngectomized patients underwent TEP for voice restoration. They were divided into two groups: group one, 43 patients with secondary TEP; and group two, 32 patients with primary TEP. Patient medical records were reviewed for data on the incidence, management and outcome of adverse events encountered during patients' follow up.

Results: Problems that arose in the patients were itemized as either early or late. The same patient could develop one or more problems in either group. The management of these problems, concerning the creation and maintenance of the TEP and associated prostheses, was noted. In group one, results were initially favourable in 91 per cent of patients and still positive in 81.4 per cent after three years. In group two, early results were favourable in all patients, and only two patients asked for late elective closure of the TEP (with a success rate of 93.7 per cent).

Conclusions: Via an intensive and multidisciplinary approach to problems, most of the inevitable adverse events could be solved adequately, minimizing the discomfort of patients who had undergone laryngectomy and indwelling voice prosthesis insertion.