This is a prospective study that looks into the prevalence of chorda tympani nerve (CTN) injury and related symptoms following varying degrees of trauma to the nerve during three common types of middle-ear operation: myringoplasty, tympanotomy and mastoidectomy. The number of patients with CTN-related symptoms varied widely between the three groups. Increased occurrence of the nerve related symptoms and a prolonged recovery time were observed in the tympanotomy group. Stretching of the nerve produced more symptomatic cases than cutting it in the myringoplasty and mastoidectomy groups. Recovery was complete in 92 per cent of the symptomatic patients by 12 months. It is important to inform patients about the possibility of CTN injury during middle-ear operations, and it should also be emphasized that symptoms related to CTN injury can occur irrespective of the type of damage to the nerve.

Bilateral traumatic facial paralysis is a very rare clinical condition. Abducens palsy, associated with bilateral traumatic paralysis, is even rarer and has not been well described in the literature. In this report, a 24-year-old male, who developed immediate bilateral facial and right abducens paralyses following a motor vehicle accident, is presented. The patient was referred for neurotologic evaluation 22 days after the injury. Electroneurography (ENoG) demonstrated 100 per cent degeneration at the first examination and, correspondingly, electromyography showed no regeneration potentials. Using high-resolution computed tomography (HRCT), a longitudinal fracture on the right and a mixed-type fracture on the left were identified. The patient had good cochlear reserve on both sides. The decision for surgery was based not on ENoG, because of the delayed referral of the patient, but on the HRCT, which showed clear fracture lines on both sides. The middle cranial fossa approach for decompression of the right facial nerve was performed on the 55th day following the trauma, and a combined procedure using the middle cranial fossa and transmastoid approaches was applied for decompression of the left facial nerve on the 75th day following the trauma. On the right, there was dense fibrosis surrounding the geniculate ganglion and the proximal tympanic segment whereas, on the left, bone fragments impinging on the geniculate ganglion, dense fibrosis surrounding the geniculate ganglion, and a less extensive fibrotic tissue surrounding the pyramidal segment were encountered. There were no complications or hearing deterioration. At the one-year follow up, the patient had House-Brackmann (HB) grade 1 recovery on the right, and HB grade 2 recovery on the left side, and the abducens palsy regressed spontaneously. The middle cranial fossa approach and its combinations can be performed safely in bilateral temporal bone fractures as labyrinthine sparing procedures if done on separate occasions.

Objective: A new technique of direct phonoplasty under local anaesthetic is described.

Background: Vocal-fold medialization is an accepted method to improve voice in patients with a paralysed vocal fold. Various materials have been used to inject into the paralysed vocal fold, resulting in medialization of the fold and improved phonation. The two established methods are direct injection under general anaesthetic and transcutaneous injection under local anaesthetic; both have advantages and disadvantages.

Method: A Pentax 80K series flexible endoscope is used to directly inject collagen into the paralysed vocal fold via a reusable 23G endoscopic needle under local anaesthetic.

Conclusion: New technology and innovation have allowed development of the new technique of direct phonoplasty under local anaesthetic. This combines the advantages of transcutaneous injection under local anaesthetic and direct injection under general anaesthetic, without their disadvantages.

The results of a nine-year series of patients who underwent long-term middle ear ventilation using a tympanotomy technique are presented. The original series of 26 cases was published in 1995. The same series has now expanded to 37 cases, which form the basis of this follow-up study. In contrast to the original series we found a high spontaneous extrusion rate (68 per cent) and in 27 per cent of cases complications necessitated removal of the subannular T tube. In favour of the technique was a low perforation rate after extrusion or removal (eight per cent). Although only nine per cent underwent re-ventilation this is unlikely to represent resolution of the middle ear effusion in the remaining cases.

We conclude that the adverse effects of the subannular tympanotomy technique for long-term ventilation of the middle ear outweigh the benefits when compared with the traditional technique of placing a T tube through a myringotomy incision.

A unique case is presented of a penetrating injury of the parotid gland and complete transection of the cartilaginous portion of the external auditory canal by a tree branch. A subsequent superficial parotidectomy along with end-to-end anastomosis of the external auditory canal and appropriate antimicrobial therapy was successful. A review of the literature did not reveal any previous similar cases.

Fractures of the frontal sinus are seen predominantly, although not exclusively, in young men and are usually the result of road traffic accidents or falls.

These types of injury may present to either ENT, Maxillofacial, Plastic or Neurosurgery teams, and understanding of a clear management protocol is desirable for each of the specialties. The optimal management of these injuries is becoming more uniformly adopted although some areas of contention still persist. The aim of treatment has always been directed at creating a ’safe sinus’ that is not complicated by the late sequelae of infection or mucocele formation. The difficulty lies in being able to predict which patients are likely to develop these complications.

The aim of this paper is to evaluate the literature and offer a rationale for the management of these injuries.

The larynx functions as a protective valve of the upper airway. An end-tracheostomy represents a risk factor for foreign body aspiration. We describe a case of tracheostomy stoma button aspiration, leading to recurrent chest infection and irreversible lung damage, necessitating a pneumonectomy. This is the first reported case of this kind. This case also emphasizes the importance of patient education and of stoma button design.

Many operative procedures have been described to treat frontal sinus disease with varying results. Obliteration of the frontal sinus is attempted when drainage procedures fail. Most large series of patients undergoing sinus obliteration have reported recurrent disease yet the management of these patients is rarely discussed. We believe Riedel’s procedure has an important role in the management of these patients. Riedel’s procedure can help eradicate frontal sinus disease and symptoms when drainage and obliteration have failed and where there is persistent disease involving the anterior wall of the frontal sinus or the sinus itself. Whilst cranialization has a role in the removal of the mucosa or contents of the frontal sinus in craniofacial resection, the morbidity associated with it make Riedel’s procedure preferable for dealing with chronic infection or locally invasive disease. Riedel’s procedure also maintains a barrier in the form of the posterior wall of the frontal sinus and the intracranial contents. Post-operative disfigurement, the main criticism of this procedure, can be reduced to some extent by chamfering the margins of the frontal sinus along with the supraorbital rims and reconstructing the anterior wall at a later date if necessary. The authors are aware that any report about frontal sinus surgery should be judged after several years follow-up, and whilst not all these cases have been asymptomatic for a decade, several have been reviewed for many years.

A 77-year-old euthyroid man developed atrial fibrillation on the fourth post-operative day following a total laryngectomy and right radical neck dissection including a hemi-thyroidectomy for a squamous cell carcinoma of the larynx with nodal metastases. The episode of atrial fibrillation coincided with an elevated serum free thyroxine of 3.36 ng/dl (43.3 pmol/L) (reference values: 0.71–1.85 ng/dl or 9.1–23.8 pmol/L), normal total triiodothyronine of 104 ng/dl (1.6 nmol/L) (reference values: 46–137 ng/dl or 0.7–2.1 nmol/L) and a suppressed thyroid-stimulating hormone (TSH) of 0.05 mIU/L (reference values: 0.35–5.0 mIU/L). These values, in relation to those prior and subsequent, suggested a surgery-induced thyroiditis. The limited literature about this controversial entity is reviewed.

Dacryocystorhinostomy (DCR) is the preferred treatment for lacrimal duct blockage. Endoscopic DCR has been practised increasingly in recent years as it avoids a facial scar and can be performed as a day procedure. Recent improvements in endonasal surgical techniqueled to success rates of up to 90per cent. However, the endonasal approach often requires septalor turbinate surgery to optimze access to the lacrimal area.

The incidence of concomitant procedures was investigated in 256 patients undergoing endonasal nonlaser DCR. In this study 55 out of 256 patients (21.5 per cent) required additional endonasal procedures to improve access to the lacrimal area.

It is therefore advisable that otolaryngologists are involved in this procedure.

This paper describes the Mills sleeve technique of ossicular reconstructionfor defects of the incus long process and reviews the results of 27 procedures. A retrospectivereview of operations was performed by eight otologists. The results are compared with those from three other reconstruction techniques (cortical bone graft, cortical bone sleeve and incus autograft).

Prostheses were supplied to surgeons who expressed an interest. Pre- and post-operative audiological data forms were analysed for each case along with a questionnaire about use of the prosthesis. The mean post-operative air bone gap (ABG) was compared with results from cortical bone sleeve, incus autograft and simple cortical bone graft reconstruction cases previously performedby the senior author.

Twenty-seven procedures were performed. Closure of the ABG to within 10dB was achieved for 44.4 per cent of Mills sleeve cases compared with 44.7 per cent for the cortical bone sleeve, 52.9 per cent for ossicular and 26.9 per cent for cortical bone grafts. The responses to a questionnaire sent to participating surgeons are discussed.

For the current follow-up period (three months to three years) the Mills sleeve prosthesis appears to be safe and easy to use with audiological results at least as good as other reconstructive techniques.

This study assessed the functional results in patients treated primarily through supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP).

Fifteen patients with a diagnosis of epidermoid carcinoma of the glottis region admitted to the Instituto Nacional de Cancerología (México) between June 2001 and September 2002 were studied. Three patients were at stage I, five at stage II, six at stage III, and one at stage IV. Both cricoarytenoid units were preserved in 12 patients, and only one in three. Each case was assessed through the clinical grading postoperative aspiration (CGPA) scale, the performance status scale for head and neck cancer (PSS-HNC), and the Karnofsky Performance Scale (KPS). Likewise, voice quality of the patients was assessed regarding tone and intensity using the SpeechViewer version 1 (IBM) and data were obtained with the Cool Edit 2000 software.

Twelve patients received phoniatric rehabilitation and three were left without rehabilitation. The average time for decannulation was 12 days and 23 days for removal of the nasogastric catheter. The degree of aspiration was 0 in four patients and one in 11. According to PSS-HNC, the mean for normalcy in the diet was 95 and the mean for those eating in public was 91. Intelligibility reached an average of 90. Karnofsky’s assessment was related to the disease and not to the treatment, as it remained at 100 per cent in most patients and was never below 80 percent. The mean intensity of quality of voice was -18 dB below normal; however, the mean frequency was 243.7 Hz.

SCPL and CHEP allows the preservation of the basic function of the larynx; however, a clear alteration in voice occurs after the procedure, although normal frequency is kept when both arytenoids are preserved. Likewise, preservation of both arytenoids shortens the time needed for cannula and feeding catheter removal. PSS-HNC, Karnofsky, and CGPA assessments demonstrated thatpatients can reach an almost normal bio-psycho-social integration. It is recommended that all patients be subjected to phoniatric rehabilitation.

The objectives in treatment of bilateral vocal fold immobility (BVFI) are to achieve adequate airway, preservation of voice quality and laryngeal competence. The present prospective study was designed to evaluate precisely the efficiency and long-term clinical outcome in a series of 13 patients with irreversible BVFI, consecutively managed with endoscopic radiosurgical posterior transverse cordotomy (ERPTC). The operation was performed endoscopically using an Ellman Radiosurgical Instrument and a specially designed electrode. Pre- and post-operative inspiratory function measurements and acoustical vocal analysis were conducted on the patients and were tested for potential statistical relation to successful rehabilitation of the airway. One-step, successful restoration of the airway was achieved in all patients. The post-operative improvement of spirometric values was statistically significant (p < 0.0001), and during the follow-up period of (six to 30) months, airway stability was demonstrated in all patients. In terms of acoustic analysis a non-significant difference was found between pre- and post-operative vocal functions (p > 0.05). This management approach offers an alternative to laser procedures, it provides a ’one-stage’ solution for permanent bilateral vocal fold immobility, and avoids terminal loss of voice quality. The authors’ data confirm the safety, ease of performance, and efficiency of ERPTC in patients with bilateral immobile vocal folds.

A variety of approaches have been employed for the reconstruction of head and neck defects and most of the techniques involve the use of arterialized vascular flaps alone, or in conjunction with other regional or local tissues. We frequently use a pectoralis major myocutaneous (PMMC) flap in our hospital in addition to other pedicled or free tissue transfers. A PMMC flap is a reliable flap with acceptable complications, needs a small learning curve, takes less time, and does not require additional investment (i.e. microscopes, loops etc). The disadvantages of the PMMC flap is that it has a restricted arc of rotation, gives a cosmetically unacceptable bulk in the neck, it is difficult in females and causes significant shoulder dysfunction. We have made a small improvization in the flap-raising technique which is helpful for the surgeon. This involves utilization of intestinal clamps to hold and cut the pectoralis major muscle.

A case of oesophageal obstruction following the removal of a tracheoesophageal valve by division is presented. The obstruction was caused by impaction of a portion of thevalve at a previously undiscovered benign oesophageal stricture. The obstruction was resolved by interventional radiology with no long-term sequelae. To the best of our knowledge this complication has not been described previously.

An interesting case is presented of a 53-year-old male who was seen with a 10-year history of intermittent, unilateral nasal obstruction following a bilateral total inferior turbinectomy. A pedunculated mass was seen in the right posterior nasal space acting as a ball valve. This was removed and found to be residual turbinate tissue.

Difficult cerebellopontine angle (CPA) tumours namely large/giant vestibular schwannomas, vestibular schwannomas with a significant anterior extension and meningiomas of the posterior surface of the petrous bone extending anterior to the internal auditory canal (IAC) have always posed a problem for the otoneurosurgeon. Modifications of the enlarged translabyrinthine approach (ETLA) specifically aimed at dealing with these tumours are not reported. The aim of this paper is to introduce the transapical extension of ETLA which involves increased circumferential drilling around the IAC beyond 270°C. The extension allows enhanced surgical control over the tumour as well as the anterior aspect of the CPA including the prepontine cistern, the Vth and VIth cranial nerves. The extension is further classified into Type I and II depending upon the extent of drilling. Type I extension entails drilling around the IAC for 300–320° and is indicated for large/giant vestibular schwannomas (large vestibular schwannoma extrameatal diameter 3–3.9 cm, giant vestibular schwannoma extrameatal diameter [ges ]4 cm) and vestibular schwannomas with significant anterior extension. Type II extension involves complete drilling around the canal for 360° and is indicated for meningiomas of the posterior surface of the petrous bone extending anterior to the IAC.

A prospective non-randomized study was designed to investigate the effects of Celon® radio-frequency thermo-ablation (RFTA) of the soft palate in patients with snoring/mild obstructive sleep apnoea. Ten patients, fulfilling various inclusion/exclusion criteria, underwent single operator sub-mucosal RFTA palatoplasty as an office procedure. Two separate procedures six weeks apart involved each patient receiving six distinct sub-mucosal lesions on each visit. Questionnaires including visual analogue scales (VAS) were used to evaluate post-operative pain and subjective snoring (scored by patient/partner). Polysomnography (PSG) was performed pre-operation and three months following the second procedure. Using non-parametric statistical analysis, a significant reduction in VAS snoring was noted from initial levels to those scored at six and 16 weeks in nine of 10 patients (p = 0.013 and p = 0.007 respectively). (Five of these nine showed a greater than 50 per cent reduction in score). Objectively, six of 10 patients had a reduction in the apnoea-hypopnea Index between the two PSGs, (four of these six showed a greater than 50 per cent reduction) however, this was not statistically significant. Subjective assessment of the PSG snoring signal by the senior author showed eight of 10 patients had either a reduced or much reduced signal at four months. VAS pain confirmed both procedures are well tolerated with minimal analgesia requirements. Minor complaints of transient mild palatal swelling, dry throat, catarrh and referred otalgia were noted and one patient developed mucosal ulceration following both procedures that healed within three weeks. Swallowing and speech were unaffected. These results confirm similar findings using the Somnus® Unit, although the Celon® device provides additional advantages ncluding inherent safety in a bipolar electrode tip, auto-stop energy application and reduced procedure time.

Complications following stapedectomy are the most common cause of litigation involving otological cases in the USA. Manipulation and placement of the prosthesis during a stapedectomy may have a profound effect on the final hearing results. Concerns have been raised over the reduced number of cases, training of residents, and the maintenance of the necessary skills to achieve consistently good results.

Temporal bone dissection is an important adjunct to developing the required skills to perform stapedectomies. However the reduced availability of specimens limits their use for teaching or practising the procedure.

In order to circumvent these problems an inexpensive and easily constructed middle-ear simulator has been developed based on materials readily available in any ENT ward. It is believed that this might help trainees develop the necessary skills to master the procedure.

Myringoplasty is an established procedure. However, the quest is on to improve the results further by studying the different influencing factors, that could possibly affect the outcome. In the present randomized prospective study of one year’s duration, 60 patients having dry, large and subtotal perforations of the tympanic membrane were subjected to myringoplasty, 30 by the overlay technique and 30 by the underlay technique keeping all other influencing factors constant. The graft take-up rate was found to be the same (93.3 per cent) in both techniques but the underlay technique was judged to be better because of its technical ease, better assessment of ossicular chain integrity and mobility, less time consumption (55 minutes vs 90 minutes), earlier healing of graft (four to six weeks vs six to eight weeks), hearing gain in more patients (92.8 per cent vs 57.1 per cent) and fewer minor complications (6.6 per cent vs 33.3 per cent).