Variant anatomy of the hypoglossal nerve is very rare. We report an unusual intra-operative finding of an aberrant branch of the hypoglossal nerve, encountered during a facial reanimation procedure.

A 50-year-old man was referred to the head and neck surgery department by the neurosurgeons for hypoglossal-facial nerve anastomosis to treat his facial paralysis, which had occurred following the removal of an intracranial neoplasm. During surgery, we identified an aberrant branch of the hypoglossal nerve, which took a more ventral and superior course in the carotid triangle, prior to entering the base of the tongue. Following further dissection, we found the main trunk of the ‘true’ hypoglossal nerve. Several interconnecting strands were seen in the proximal aspect of both the aberrant branch and the main trunk of the hypoglossal nerve. These interconnecting fibres appeared to have tethered the main trunk into an abnormal anatomical position.

As far as we can ascertain, this is the first report of an aberrant branch of the hypoglossal nerve. Although this variant would appear to be extremely rare, surgeons must consider all variations of this nerve during head and neck procedures, in order to minimise iatrogenic complications.

We report an extremely rare case of isolated primary sinonasal amyloidosis.

A case report and comprehensive literature review are presented. Common symptoms, signs and treatment options are examined, and used to derive an algorithm with which the practising otolaryngologist can diagnose and manage this condition.

Only 15 cases of true primary idiopathic amyloid restricted to the sinonasal tract have previously been reported. Isolated sinonasal amyloid presents with common rhinological symptoms which mimic chronic rhinosinusitis, i.e. nasal obstruction, nasal discharge, epistaxis, ‘glue ear’ and post-nasal drip. The lesion itself can appear as a simple inflammatory polyp. In children, the symptoms are easily attributed to enlarged adenoids. Although there is a concern that surgically induced trauma to the paranasal mucosa might incite reactive amyloid deposition, this seems not to be the case, and surgery provides symptomatic relief in the majority of patients.

This article is the first to report the characteristic features of isolated primary sinonasal amyloidosis. The evidence suggests that meticulous surgery can produce substantial symptomatic improvement in these patients.

To describe three rare cases of nasolacrimal relapse of nasopharyngeal carcinoma, and to discuss the route of tumour spread from nasopharynx to lacrimal system as well as the relevant computed tomography findings.

We report three cases of nasolacrimal relapse in patients with previously treated nasopharyngeal carcinoma. The common initial presentations in these cases were epiphora and medial canthal swelling. The tumour spread from the nasopharynx to the lacrimal sac along the lateral nasal wall and nasolacrimal canal. Computed tomography demonstrated nasolacrimal canal invasion and osteomeatal complex obliteration by the tumour. Distant metastasis was detected in two cases.

More targeted radiotherapy should be delivered to prevent under-treatment of nasopharyngeal carcinoma. Nasolacrimal relapse of nasopharyngeal carcinoma is an advanced disease with a poor prognosis.

Fungiform papillomas are benign mucosal neoplasms presenting as a unilateral exophytic mass involving the anterior portion of the nasal septum. In this study, we present an exceptional case of a bilateral fungiform papilloma with a synchronous verrucous carcinoma of the nasal septum.

A case study with a review of the literature concerning malignant changes in fungiform papilloma.

The general consensus in most of the literature is that malignant change in fungiform papilloma is exceptional. Our patient is probably the third reported case of verrucous carcinoma of the nasal septum, and the first report of a bilateral fungiform papilloma with a synchronous verrucous carcinoma. The tumour was subjected to complete surgical removal in the first instance. There was no recurrence at follow up seven months after surgery.

Although fungiform papillomas are generally not premalignant, occasional malignant transformation may occur. Thus, they must be managed with the utmost cautiousness.

We discuss the use of balloon dilatation to relieve supraglottic stenosis caused by mucous membrane plasmacytosis.

A 54-year-old man with a known diagnosis of mucous membrane plasmacytosis presented with dysphonia and worsening airway obstruction which required a tracheostomy. He underwent balloon dilatation of the supraglottic larynx using an angioplasty balloon within sequentially sized endotracheal tubes. This enabled successful decannulation, with minimal re-stenosis at eight-month follow up.

To our knowledge, this is the first reported case of supraglottic stenosis caused by plasmacytosis to be successfully treated using this method. We have shown that this minimally invasive technique deals effectively with a complex airway and minimises re-stenosis.

Pathological paranasal sinus expansion secondary to air is uncommon. However, this condition may be symptomatic or cosmetically apparent, requiring surgical intervention. Various terms have been used to describe this condition, and nomenclature is controversial.

An 18-year-old man presented with right facial pain, and was subsequently found to have pneumosinus dilatans of the maxillary sinus. A search was conducted of the PubMed, Medline and Embase databases, using the key words ‘pneumosinus dilatans’, ‘pneumoc(o)ele’, ‘pneumatoc(o)ele’ and ‘maxillary sinus’. Articles were also hand-searched. Relevant articles published in English were reviewed.

The literature review identified 36 cases involving the maxillary sinus (including the present case), with 19 cases reported as pneumosinus dilatans, 12 as pneumocoeles, two as pneumatocoeles, two as pneumosinus dilatans multiplex and one as an air cyst. However, based on the strict classification described by Urken et al., the majority of these cases should be reclassified as pneumocoeles.

Whilst the nomenclature of this pathology is confusing, distinctions of terminology do not alter the management. Hence, we support the use of the term ‘air cyst’, to incorporate all these lesions.

We report an interesting case involving a child with a branchial cleft anomaly with two fistulous tracts, one of which was associated with an unusual otoscopic finding.

A seven-year-old girl presented with an apparent type II first branchial cleft cyst after an acute infection. Parotidectomy and excision of the tract were performed, with subsequent development of pre-auricular swelling three months later. Further surgery was performed to remove a second duplication anomaly of the external auditory canal. Otomicroscopy showed a fibrous band arising from the wall of the canal and attached to the tympanic membrane at the umbo.

Otoscopic findings on physical examination can be important diagnostic clues in the early recognition of branchial cleft anomalies. The classification system proposed by Work may fail to describe some branchial cleft lesions.

We report the first published description of transoral use of the transnasal flexible laryngoesophagoscope during surgical correction of choanal atresia.

A four-month-old boy was referred to the ear, nose and throat department by his general practitioner with a two-week history of left-sided, watery, green, nasal discharge. A diagnosis of choanal atresia was made. The child underwent successful surgical correction which incorporated transoral use of a transnasal flexible laryngoesophagoscope.

When used transorally, the transnasal flexible laryngoesophagoscope's ability to provide omnidirectional visualisation together with high definition picture clarity significantly improves the operative field of view. This endoscope's incorporated suction and insufflation functions and its facility to pass extra instruments via the endoscope port are of particular advantage for this type of procedure.

To highlight a rare cause of Horner's syndrome, and to review the management of blunt carotid artery injury.

Literature search via PubMed for related articles.

Horner's syndrome and blunt carotid artery injury are rare phenomena; sexual asphyxia as a cause has not previously been reported. This case is also the first of its kind to have radiological evidence of injury to the external carotid artery but not the internal carotid artery. In Horner's syndrome, additional symptoms of ipsilateral headache or neck pain, tinnitus, or any cerebral ischaemic symptoms should raise suspicion of blunt carotid injury.

Blunt carotid artery injury is a potentially fatal condition and can present without radiological evidence. Early recognition and management with anticoagulants or antiplatelet drugs is crucial to prevent mortality and morbidity.

We report a case of hypopharyngeal swelling secondary to a spontaneous thyroid cyst haemorrhage. Haemorrhage is a known complication of thyroid cysts, and usually presents as external swelling and localised pain.

A 93-year-old woman developed hypopharyngeal swelling, dysphagia and odynophagia. A computed tomography scan was consistent with thyroid cyst haemorrhage. The patient was treated with needle aspiration and intravenous steroid injections, with full recovery at thyroid clinic review.

To our best knowledge, there has been no previous report of a hypopharyngeal swelling occurring secondary to spontaneous thyroid cyst haemorrhage. Our case is unusual because of the risk of airway compromise at the level of the hypopharynx, secondary to thyroid cyst haemorrhage.

We describe the first reported case of a malignant glomus tumour of the larynx.

Case report and review of the world literature concerning malignant glomus tumours.

A 37-year-old man presented with progressive hoarseness and dyspnoea. A smooth, right-sided laryngeal mass was found on flexible nasolaryngoscopy. Initial biopsy of this lesion was reported as a true ‘glomus tumour’, which is a benign lesion. Wide local excision was performed. The final histology of this specimen showed it to be a ‘malignant glomus tumour’. Immunohistochemistry was positive for smooth muscle actin, collagen type IV, vimentin and cluster of differentiation 34 glycoprotein. Total laryngectomy was then performed as a definitive curative procedure.

Glomus tumour is rarely found in visceral locations. This tumour and its malignant counterpart are rare differential diagnoses of laryngeal masses.

We report a case of an internal carotid artery aneurysm presenting as orofacial pain.

Case report and discussion.

A 59-year-old patient presented with a four-year history of chronic oral pain accompanied by a right-sided occipital headache. No local organic pathology was detected, and a provisional diagnosis of persistent idiopathic facial pain was made. A neurosurgery referral was made to exclude neurovascular pathology, which resulted in the detection of an aneurysm originating from the right posterior communicating artery. This was successfully treated by coil embolisation, with subsequent resolution of symptoms.

In this patient, an atypical history of pain with no other neurological signs or symptoms, other than accompanying occipital headache, led to the discovery of an intracranial aneurysm. This case highlights the need for appropriate referral and imaging in cases in which the clinical history and findings are not classical, and also emphasises the need for interdisciplinary management.

We report an extremely rare case of a fungus ball within a mucocele of the sphenoid sinus and infratemporal fossa.

A 62-year-old woman was referred for evaluation of a mass lesion in the left sphenoid sinus and infratemporal fossa. Endoscopic examination of the nasal cavity was unremarkable. Computed tomography showed a non-enhancing, expansile mass with calcifications in the sphenoid and infratemporal fossa; T2-weighted magnetic resonance imaging revealed marked hypointense signals within the sphenoid sinus mass, with an intermediate signal intensity. A presumptive diagnosis of a mucocele was made. During surgery, a profuse amount of yellow fluid was drained from the mucocele. Clay-like material was noted within the mucocele, corresponding to the hypointense magnetic resonance imaging signals; this was identified as aspergillus on histopathological examination. Radiological findings for a fungus ball within a mucocele can be similar to those for allergic fungal sinusitis, which shows mixed low and high attenuation on computed tomography and low-signal intensity on T2-weighted magnetic resonance imaging, within an expansile, cystic lesion.

Although an association between a fungus ball and a mucocele is rare in the paranasal sinuses, this disease entity should be considered in the differential diagnosis of expansile, cystic sinus lesions.

Periorbital cellulitis secondary to rhinosinusitis is common. However, very rarely this can be complicated by a lacrimal gland abscess. We report such a case.

We present a case report and literature review concerning lacrimal gland abscess secondary to periorbital cellulitis.

Due to the location of this condition, prompt assessment and management is vital to avoid potential ophthalmological and neurological complications. Our patient failed to respond to initial conservative medical treatment, and was subsequently identified as having a lacrimal gland abscess, confirmed on contrast-enhanced computed tomography. Following definitive surgical treatment, the patient's clinical course improved. This case furthers our knowledge of this condition, and adds to the two previously reported paediatric cases.

This case emphasises the importance of prompt management, and the fact that failure of clinical improvement following orbital decompression should alert the clinician to the rare possibility of an associated lacrimal gland abscess. The case also emphasises the key role of imaging and a multidisciplinary team approach when managing this condition.

Imatinib therapy has been successful in gastrointestinal stromal tumours containing mutation of the KIT gene. However, there are few reported cases of successful imatinib therapy in patients with melanoma containing KIT gene mutation or c-kit protein expression.

A 52-year-old man developed metastatic melanoma from a primary melanoma in the left side of the nasopharynx. The tumour was positive for c-kit protein, and there was a KIT mutation in exon 11. He was treated with imatinib. A follow-up scan one year later showed a complete response. Treatment targeting the biological characteristics of melanoma proved successful in this patient.

We present the first reported case of a paraganglioma of the larynx occurring concurrently with squamous cell carcinoma in an irradiated neck.

We present a case report and a literature review of paraganglioma of the larynx.

A 78-year-old woman was found to have a mass on the laryngeal surface of the epiglottis and non-functioning larynx, four months after radical radiotherapy for biopsy-proven squamous cell carcinoma. Repeated positron emission tomography computed tomography was highly suggestive of residual malignancy. Given these findings, and the fact that the patient was aspirating, she was treated with total laryngectomy, and was found to have a paraganglioma of the larynx.

This is the first report of such a case. Its importance is three-fold in that it demonstrates: the coexistence of paraganglioma and squamous cell carcinoma; the difficulties that can be encountered in the diagnosis; and the use of radiotherapy in the treatment of paraganglioma.

To increase awareness of cervical osteophytes as an extremely rare cause of recurrent laryngeal nerve palsy; to outline the clinical approach to patients with unilateral vocal fold paralysis and to provide an update on the current management of osteoarthritis and osteophytes.

An elderly man presented with right unilateral vocal fold immobility and a small phonatory gap. By a diagnosis of exclusion, a cervical osteophyte at the level of the sixth and seventh cervical vertebrae was shown to be the cause. The patient responded to speech therapy and no further intervention was required.

A literature review, using Medline, identified only one previously published case of vocal fold paralysis due to osteophytes secondary to osteoarthritis.

The aetiology of unilateral paralysis of the hemilarynx must be fully investigated, as the innervating system has a protracted course, particularly on the left side. Degenerative cervical spine disease, although rare, should be considered as part of the differential diagnosis.

To present the case of a ‘lost’ nasogastric tube and to highlight the importance of imaging and/or chest X-ray after nasogastric tube insertion, especially in unreliable patients.

A 50-year-old man, undergoing radiotherapy treatment for squamous cell carcinoma of the tongue base, was admitted for pain control and nasogastric tube feeding. This patient required multiple nasogastric tubes over a two-week period. The patient repeatedly denied pulling the nasogastric tube out and we were unable to establish the exact mode of nasogastric tube removal. On one such occasion another tube was inserted and a check X-ray showed two feeding tubes; the latest one was lying in the left main bronchus and the old nasogastric tube was observed in the oesophagus, with its upper end jutting above the hypopharynx. It was apparent that the patient had somehow cut the tube and swallowed it.

This case not only illustrates the importance of flexible nasendoscopy and/or chest X-ray for checking the position of the nasogastric tube, but also highlights that some patients are not tolerant of nasogastric tubes. The use of nasogastric tubes should be avoided in these patients to prevent any self-inflicted injury.

We report a rare case of bilateral maxillary mucoceles. This was the primary presentation in a child with an underlying diagnosis of cystic fibrosis.

A five-month-old infant presented with isolated symptoms of nasal congestion. Initial examination and investigation with computed tomography identified the cause to be bilateral maxillary mucoceles. The child was investigated for cystic fibrosis and found to be positive. Given the young age and anatomy, a modified surgical approach was used to treat the mucoceles, comprising endoscopic and bilateral uncapping of the maxillary mucocele, uncinectomy, and middle meatal antrostomy. The child was then followed up with appropriate treatment for cystic fibrosis. At six-week follow up, there was no recurrence of symptoms.

Maxillary mucoceles are extremely rare but can present in patients with chronic sinusitis or cystic fibrosis. To our knowledge, there are no prior reports of this condition being the primary indicator of underlying cystic fibrosis in the absence of upper respiratory tract symptoms. Doctors should be aware that mucoceles can present in very young individuals and may indicate an underlying diagnosis of cystic fibrosis. A high index of clinical suspicion will avoid delays in diagnosis and long-term management.