We report an extremely rare case of coexisting, ipsilateral nonrecurrent inferior laryngeal nerve and recurrent inferior laryngeal nerve.

We present a case report and a review of the world literature concerning ipsilateral nonrecurrent inferior laryngeal nerve and recurrent inferior laryngeal nerve.

The presence of a coexisting, ipsilateral nonrecurrent inferior laryngeal nerve and recurrent inferior laryngeal nerve is a very rare embryological aberration which is associated with a right subclavian artery originating from the aortic arch. We report a case of coexisting, ipsilateral nonrecurrent and recurrent inferior laryngeal nerves associated with this vascular anomaly.

The surgeon must be aware of the possibility of coexisting, ipsilateral nonrecurrent inferior laryngeal nerve and recurrent inferior laryngeal nerve, and thus must trace the nerve in its entirety. Occasionally, what appears to be a nonrecurrent inferior laryngeal nerve will actually be a communicating branch between the recurrent inferior laryngeal nerve and the oesophageal or sympathetic ganglia. If such a neurological variant is present, the consequences of careless dissection could include not only vocal fold paralysis but also dysphagia (if the pharyngeal and oesophageal branches of nonrecurrent or recurrent inferior laryngeal nerve are injured).

Throat packs are employed in nasal surgery to prevent contamination of the upper aerodigestive tract. Their use is thought to reduce the risk of aspiration and post-operative nausea and vomiting. However, use of throat packs may also be accompanied by increased throat pain. In order to inform our clinical practice, the evidence base for throat pack insertion was reviewed.

A search was made of the Pubmed database from the 1950s to March 2008. Four randomised, controlled, clinical trials were reviewed.

All the trials had significant methodological weakness. In all but one, no power calculations were done. There were inconsistencies in the measurement of pain and heterogeneity of rhinological procedures. The one adequately powered trial could not demonstrate a difference in post-operative nausea and vomiting with the use of throat packs (β error = 20 per cent).

Further, adequately powered trials are required involving patients undergoing rhinological procedures with a higher risk of blood contamination (e.g. functional endoscopic sinus surgery), in order to provide definitive evidence on the morbidity of throat packs in rhinological procedures.

Inverted nasal papilloma is a benign tumour with variable biological behaviour. It is a unique neoplasm and is often difficult to manage, being characterised by a tendency to recur following excision, an association with malignancy and an ability to destroy bone. Radiological diagnosis has traditionally been based on computed tomography, but it is often impossible to differentiate between polyps with entrapped debris and inverted nasal papilloma. Magnetic resonance imaging, especially T2-weighted images, is perhaps a better tool in differentiating inverted nasal papilloma from other nasal lesions, and has recently been advocated as the imaging modality of choice.

To review the evidence on the ideal imaging modality for pre-operative planning of surgery for patients with histologically proven inverted nasal papilloma.

A systematic review of studies was undertaken, focusing on radiological assessment of inverted nasal papilloma (primary and recurrent). All English language articles were potentially included in the review. However, we excluded single case reports, case series, pictorial essays, ‘teaching’ reviews and reviews of inverted nasal papilloma not focusing on pre-operative imaging.

Sixteen studies were identified based on our search strategy. Only 10 fulfilled our criteria. Computed tomography scanning was the standard imaging modality of choice for assessing sinus involvement of inverted papilloma and for planning the extent of surgery. T2-weighted magnetic resonance imaging scans were able to distinguish tumour (intermediate signal) from inflammatory tissues (bright signal), but not post-operative scarring from recurrent tumour. No studies were found which compared the specificity and sensitivity of magnetic resonance imaging and computed tomography in the accurate pre-operative identification of the extent of inverted papilloma.

There is currently not enough evidence to suggest one sole modality as providing optimum imaging for inverted nasal papilloma. Computed tomography remains the imaging modality of first choice for inverted nasal papilloma, despite certain disadvantages. Magnetic resonance imaging is able to distinguish tumour from inflammation and is advocated as a better tool for recurrent tumour, but bone destruction of sinus walls is less easy to recognise, compared with computed tomography. Evaluation of sinus tumours usually involves both imaging modalities, and inverted nasal papilloma should be included within this pathological group. The cohort of patients is usually small, so cost-effectiveness should not generally be an issue when considering whether to use computed tomography, magnetic resonance imaging or both. A well structured, prospective study is needed to evaluate the efficacy of magnetic resonance imaging versus computed tomography for pre-operative planning of histologically proven inverted nasal papilloma.

To study the effects of hypobaric pressure chamber exposure on the cochlear frequency selectivity of subjects with monaural, fluctuating, low-frequency hearing loss, such as occurs in Ménière's disease.

We used a hypobaric pressure chamber to create relative underpressure in the ear canal, in order to impose positive pressure gradients on the inner ear. Psychophysical tuning curves, transiently evoked otoacoustic emissions and speech recognition scores in noise were measured in 10 subjects with fluctuating, low-frequency hearing loss, before and after pressure exposure.

After the exposure, subjects’ overall pure tone averages showed no improvement, but individual results showed improved speech recognition scores in noise (six subjects), increased transiently evoked otoacoustic emission strength (three subjects) and increased psychophysical tuning curve steepness (two subjects). Deteriorations were also seen, mainly in psychophysical tuning curves. No association could be established between the different tests, and the measured parameters could not predict subjective improvement.

The results suggest variable effects of hypobaric pressure exposure on inner-ear physiology.

Following a report of sudden hearing loss in a patient taking phosphodiesterase type 5 inhibitor, and a Food and Drug Administration announcement concerning this class of drugs, a study was planned to investigate if ototoxicity occurs in patients using phosphodiesterase 5 inhibitor for erectile dysfunction.

Eighteen patients with erectile dysfunction who had been using phosphodiesterase 5 inhibitor were included in the study. Audiometric tests were performed on all patients, between the frequencies 250 and 16 000 Hz, before and 1, 5 and 72 hours after drug ingestion.

Four patients showed a unilateral threshold decrease compatible with ototoxicity criteria; this change was reversible. A statistically significant difference in pre- versus post-drug hearing thresholds was observed in the right ear at 10 000 Hz (p = 0.008). There were no statistically significant hearing threshold differences at any other frequencies (p > 0.05).

Although temporary ototoxicity was noted in four patients, we could not find any permanent, deleterious effect of phosphodiesterase type 5 inhibitor on hearing thresholds.

The aim of this study was to investigate the impact of cochlear implant electrode insertion on middle-ear low frequency function in humans.

Preservation of residual low frequency hearing with addition of electrical speech processing can improve the speech perception abilities and hearing in noise of cochlear implant users. Preservation of low frequency hearing requires an intact middle-ear conductive mechanism in addition to intact inner-ear mechanisms. Little is known about the effect of a cochlear implant electrode on middle-ear function.

Stapes displacement was measured in seven patients undergoing cochlear implantation. Measurements were carried out intra-operatively before and after electrode insertion. Each patient acted as his or her own control. Sound was delivered into the external auditory canal via a speaker and calibrated via a probe microphone. The speaker and probe microphone were integrated into an individually custom-made ear mould. Ossicular displacement in response to a multisine stimulus at 80 dB SPL was measured at the incudostapedial joint via the posterior tympanotomy, using an operating microscope mounted laser Doppler vibrometry system.

Insertion of a cochlear implant electrode into the scala tympani had a variable effect on stapes displacement. In three patients, there was little change in stapes displacement following electrode insertion. In two patients, there was a significant increase, while in a further two there was a significant reduction in stapes displacement. This variability may reflect alteration of cochlear impedance, possibly due to differing loss of perilymph associated with the electrode insertion.

Insertion of a cochlear implant electrode produces a change in stapes displacement at low frequencies, which may have an effect on residual low frequency hearing thresholds.

To evaluate the hearing results of a large series of primary stapedotomies, according to American Academy of Otolaryngology, Head and Neck Surgery guidelines and Amsterdam hearing evaluation plots.

Retrospective chart review.

The charts for 1369 consecutive stapedotomy cases were reviewed; 1145 cases of primary stapedotomy were included. Raw data from the audiometric database were evaluated using Amsterdam hearing evaluation plots. The effect on outcomes of using different audiological parameters was analysed.

A significant improvement was demonstrated in mean post-operative air conduction and speech reception thresholds, with no change in bone conduction. Air–bone gap closure of 10 dB or more was achieved in 82 per cent of cases. A ‘dead ear’ occurred in one patient (0.1 per cent).

This study reports the largest series of primary stapedotomies evaluated with Amsterdam hearing evaluation plots. This method enables visual identification of successful and unfavourable results, providing more accurate and detailed presentation of surgical outcomes.

To compare the procedure, results and complications of conventional septoplasty with those of endoscopic septoplasty, in cases of limited septal deviation and septal spurs.

Prospective study; interventional type; randomised block design; comparative clinical trial.

We included in the study 80 patients presenting with limited septal deviation, septal spur with nasal obstruction, or deviated septum with septal correction was required in order to access the ostio-meatal complex (OMC) for functional endoscopic sinus surgery. Of these 12 were children with septal deviation producing significant nasal obstruction. All patients were divided into two groups- with one undergoing conventional and the other endoscopic septoplasty. Post-operative assessment was carried out one month, three months and one to two years after the procedure.

Post-operative complications such as haemorrhage, infraorbital oedema, nasal pain and in-patient hospital was slightly more in the conventional septoplasty group.

No statistically significant difference was found between the conventional and endoscopic septoplasty groups, as assessed by subjective and objective evaluation.

To identify measurements that may help intra-operative localisation of the sphenopalatine foramen.

The study used three-dimensional surgical navigation software to study radiological anatomy, in order to define the distances and angulations between identifiable bony landmarks and the sphenopalatine foramen.

The distance from the anterior nasal spine to the sphenopalatine foramen was 59 mm (±4 mm; inter-observer variation = 0.866; intra-observer variation = 0.822). The distance from the piriform aperture to the sphenopalatine foramen was 48 mm (±4 mm; inter-observer variation = 0.828; intra-observer variation = 0.779). The angle of elevation from the nasal floor to the sphenopalatine foramen was 22° (±3°; inter-observer variation = 0.441; intra-observer variation = 0.499).

The sphenopalatine foramen is consistently identifiable on three-dimensional, reconstructed computed tomography scans. Repeatable measurements were obtained. The centre point of the foramen lies 59 mm from the anterior nasal spine at 22° elevation above the plane of the hard palate and 48 mm from the piriform aperture. We discuss how these data could be used to facilitate intra-operative location of the sphenopalatine foramen in difficult cases.

Sleep apnoea, whether obstructive or central, is usually diagnosed by polysomnography. A simpler tool for screening high risk populations may be of value.

We compared a portable device using nasal pressure cannulae and a high-sensitivity pressure sensor (the ApneaLink®) with our standard polysomnography technique for diagnosing sleep apnoea (using the Embletta® device), in 67 patients being investigated for possible sleep apnoea. The patients' average age was 52.6, 79 per cent were male, the mean body mass index was 32.3, and the mean Epworth sleepiness score was 13.0.

Twenty-five patients (45 per cent) were identified as having an apnoea–hypopnoea index of >15, as measured by the Embletta. The mean (standard deviation) apnoea–hypopnoea index was 21.5 ± 23.0 as measured by the Embletta and 24.3 ± 26.2 as measured by the ApneaLink. The sensitivity of the ApneaLink for an apnoea–hypopnoea index cut-off point of 15 was 92 per cent and the specificity was 96.7 per cent. The negative predictive value of the ApneaLink for an apnoea–hypopnoea index of ≤15 was 94 per cent.

The ApneaLink is a useful tool for screening patients thought to have possible sleep apnoea, and for selecting patients for definitive diagnostic testing.

To evaluate the efficacy of bipolar radiofrequency volumetric tissue reduction, using Sutter® technology, in the treatment of snoring and mild obstructive sleep apnoea.

Prospective, non-randomised trial.

Fifty-two patients with simple snoring and mild obstructive sleep apnoea underwent bipolar radiofrequency palate reduction under local anaesthesia.

All patients were Friedman stage II and III, with tonsil sizes graded as zero, one or two, a mean body mass index of 22.6, and a mean age of 36.2 years. Seventy-seven per cent of patients reported improvement in their snoring; patients' mean snoring level (assessed by visual analogue scale) improved from 8.9 to 3.4 (p < 0.05). Eighty-three per cent of patients reported an improvement in their Epworth sleepiness scale score, from a mean of 14.6 to 9.5. Seven out of the 17 patients (41.2 per cent) met the surgical success criteria (i.e. at least a 50 per cent reduction of the pre-procedure apnoea–hypopnoea index, and a post-procedure apnoea–hypopnoea index of below 15). Patients' mean apnoea–hypopnoea index improved from 13.6 to 9.8, and their mean lowest oxygen saturation improved from 88.3 to 92.5 per cent. Eighty-two per cent of patients reported an improvement in their quality of life as a result of the procedure.

One session of Sutter bipolar radiofrequency tissue volume reduction represents a viable method of treating snoring and mild obstructive sleep apnoea, with good results.

Methods of perceptual voice evaluation have yet to achieve satisfactory consistency; complete acceptance of a recognised clinical protocol is still some way off.

Three speech and language therapists rated the voices of 43 patients attending the problem asthma clinic of a teaching hospital, according to the grade-roughness-breathiness-asthenicity-strain (GRBAS) scale and other perceptual categories.

Use of the GRBAS scale achieved only a 64.7 per cent inter-rater reliability and a 69.6 per cent intra-rater reliability for the grade component. One rater achieved a higher degree of consistency. Improved concordance on the GRBAS scale was observed for subjects with laryngeal abnormalities. Raters failed to reach any useful level of agreement in the other categories employed, except for perceived gender.

These results should sound a note of caution regarding routine adoption of the GRBAS scale for characterising voice quality for clinical purposes. The importance of training and the use of perceptual anchors for reliable perceptual rating need to be further investigated.

The commonest form of extrapulmonary tuberculosis is tubercular cervical lymphadenitis, or scrofula.

A total of 1827 patients with cervical lymphadenopathy who presented to various out-patients clinics of our institution were studied over a three-year period. Eight hundred and ninety-three (48.87 per cent) of these patients had lesions of tubercular origin. The most common observation was unilateral, matted adenopathy in female patients aged between 11 and 20 years and without constitutional symptoms of tuberculosis. Posterior triangle nodes were affected in 43.8 per cent of cases, followed by upper deep cervical nodes in 33.9 per cent. Fine needle aspiration cytology constituted the main diagnostic tool, with a positive yield in 90 per cent of patients. Polymerase chain reaction analysis was performed in 126 patients, with a sensitivity of 63 per cent. Only 18 per cent of patients had associated pulmonary tuberculosis, the rest having isolated involvement of cervical nodes. Medical treatment with anti-tubercular drugs for a period of six months formed the mainstay of treatment and cure. Surgical management was reserved for selected refractory patients.

Tubercular cervical lymphadenitis can readily be diagnosed by fine needle aspiration cytology, a simple and cost-effective test. The disease can be cured completely by a short course of anti-tubercular chemotherapy, without surgical intervention.

To highlight a poorly known anatomical variation of the lateral lobe of the thyroid gland, which can be useful in identifying the recurrent laryngeal nerve during thyroid surgery.

We performed a three-year prospective study of 79 thyroid surgery patients. Great attention was paid to anatomical variations of the thyroid gland (i.e. the presence or absence of a distinct tubercle of Zuckerkandl), the recurrent laryngeal nerve and the location of the parathyroid glands.

A total of 71 right lobectomies and 74 left lobectomies were performed. Five tubercles of Zuckerkandl were identified (7.04 per cent of cases) and were useful in detecting the recurrent laryngeal nerve (but only on the right side).

The tubercle of Zuckerkandl is a poorly known and variable anatomical feature of the thyroid gland which may not, in fact, be so rare. It arises for embryological reasons, and it can be a reliable anatomical landmark for identifying the recurrent laryngeal nerve during thyroid surgery. It should be included in the Nomina Anatomica as the ‘processus posterior glandulae thyroideae’ described by Zuckerkandl.

We evaluated the efficacy and safety of the extra-long Montgomery T tube for the management of major airway obstruction in tertiary care patients in Taiwan.

Eleven patients with major airway stenosis treated with an extra-long Montgomery T tube between April 2004 and December 2006 were retrospectively reviewed. Five patients had tracheostomy stenosis, two had intubation stenosis, one had traumatic stenosis, one had corrosive stenosis, one had laser burn stenosis and one had tubercular stenosis. All patients underwent three-dimensional airway reconstruction and endoscopic evaluation of airway stenosis. After determining the severity and location of airway stenosis, rigid bronchotherapy and Montgomery T tube placement were performed by rigid bronchoscopy.

The overall procedural success rate was 100 per cent. Three (27 per cent) patients were weaned from artificial ventilation, and all patients exhibited improved respiratory and functional status. No major post-operative complications or mortality were observed. At follow up (mean, 21.5 months), the decannulation rate was 27 per cent, and eight (73 per cent) patients had stable T tube ventilation. In four patients, granulation over the end of the T tube was controlled by endoscopic procedures. Three patients with stents above the vocal folds showed aspiration and required further intervention (i.e. one nasogastric feeding tube for nutrient supplement, one feeding jejunostomy and one stent shortening to decrease aspiration).

The extra-long Montgomery T tube is an effective and safe method for treating major airway obstruction in the supra-glottic to lower tracheal region.

To estimate the sensitivity and specificity of computed tomography used for the detection of extranodal spread of metastatic head and neck squamous cell carcinoma, by experienced head and neck radiologists.

Participants had undergone a neck dissection for head and neck squamous cell carcinoma, together with computed tomography scanning prior to surgery (accessible for reporting). Computed tomography images were independently examined by two experienced head and neck radiologists. Nodal involvement by squamous cell carcinoma and the presence or absence of extranodal spread were recorded. Results were compared to the histological specimen. The sensitivity, specificity and positive predictive value of using computed tomography for the detection of nodal involvement and presence or absence of extranodal spread were estimated, and 95 per cent confidence intervals were calculated.

The study analysed 149 neck dissections. When using computed tomography to detect the extranodal spread of head and neck squamous cell carcinoma, radiologists A and B had sensitivities of 66 and 80 per cent, specificities of 91 and 90 per cent, and positive predictive values of 85 and 87 per cent, respectively.

The sensitivity and specificity of radiological detection of extranodal spread from head and neck squamous cell carcinoma is not well reported in the literature. Accuracy of reporting improves in the hands of experienced head and neck radiologists. This finding has clinical implications for surgical planning and adjuvant therapy requirements.

Office-based laryngeal injection for the treatment of a variety of voice disorders is an established practice. Various methods of delivery to the vocal folds are in practice.

We present a simple and repeatable method of injecting botulinum toxin into the larynx.

Botulinum toxin A (Botox®) was delivered into the larynx using a channelled fibre-optic laryngoscope under local anaesthetic, in an office setting.

Seven patients received regular botulinum toxin injections, via our preferred method. The treatment intervals and dosage regime varied depending on patient requirements. The procedure was carried out in an office setting, with minimal discomfort and inconvenience to the patient.

We present a method of botulinum toxin delivery to the larynx which is simple, easily repeatable and simply learnt by the otolaryngologist familiar with fibre-optic laryngoscope usage. This method is also comfortable and convenient for the patient.

To propose an alternative site of thyroid drain placement.

During thyroid surgery, post-operative drains are often placed. It is common practice to bring out the drain lateral to the wound, often creating an additional, unsightly scar.

We have found excellent cosmesis is achieved by bringing out the drain in the midline in a sub-mental skin crease, with the scar hidden in the chin shadow. In our experience, such drain placement is a safe, straightforward method with an excellent cosmetic result.