Nasal polyps are common, affecting one to four per cent of the population. Their cause, however, remains unknown and it is possible that it is not the same in all patients. They have a clear association with asthma, aspirin sensitivity and cystic fibrosis. Histologically they demonstrate large quantities of extracellular fluid, mast cell degranulation and an infiltrate of inflammatory cells, usually eosinophils. While this appearance would suggest an allergic pathology there is little conclusive evidence to support this in most patients. There is, however, some preliminary evidence to suggest that a local allergic process could be the cause. While allergic fungal sinusitis is a well defined clinical entity with recognized diagnostic criteria the ubiquitous nature of fungal spores makes the role of fungal infection in patients with nasal polyps difficult to determine and currently this remains unclear.

Surgical treatment of nasal polyps has declined in recent years as the benefits of medical treatment have become increasingly recognized. There is good evidence to support the use of corticosteroids both as a primary and post-operative treatment in the majority of patients. Other medical treatments require further evaluation before they could be considered a viable alternative to steroids. Assessment of the literature regarding surgical intervention is difficult and there is little evidence on which to base a surgical treatment philosophy. The authors believe that an endoscopic approach using a microdebrider facilitates accurate removal of polyps with preservation of normal anatomy.

Ménière’s disease is a vestibular disorder characterized by episodic vertigo, tinnitus, fluctuant hearing loss, and ear fullness, with vertiginous attacks being the most disabling complaint. The effectiveness of conservative treatment has been variable, while surgical techniques provide more permanent relief from vertigo, but pose possible morbidity and cochlear risk. Intratympanic administration of gentamicin has been proposed as an alternative for patients with debilitating Ménière’s disease who have failed to respond to standard medical treatment. The goal of such treatment is to control vertigo by partially or completely destroying the vestibular system, while at the same time maintaining hearing.

In this review we present the current medical literature on pathophysiology, pharmacokinetics, administration methods, dosage, treatment protocols, and problems related to intratympanic administration of gentamicin for patients with MD.

Intratympanic gentamicin administration is a simple medical modality for treatment of persistent vertigo in patients with Ménière’s disease. According to recent world research protocols, we propose the instillation of gentamicin by transtympanic injection, as a quick, easy, well-tolerated, ambulatory and cost-effective technique. Drug solution concentrations should be dependent on the frequency, intensity and duration of vertigo spells, as well as the degree of existing hearing loss, thus providing progressive vertigo relief with a low possibility of secondary deafness.

Philipp Friedrich Arnold and Ludvig Levin Jacobson were two of the greatest anatomists of the 19th century. Within this paper their backgrounds and their contribution to the development of various aspects of head and neck anatomy are considered.

Maldevelopment of the first branchial cleft can produce a broad spectrum of anomalies in its derivative structure, the external auditory canal (EAC). Failure of the cleft to develop normally can result in either the absence of a normally patent EAC (atresia, or stenosis) or a duplication anomaly (cyst, sinus, or fistula). Despite their common origins, the coexistence of these anatomical abnormalities is quite unusual. We present four patients with both aural atresia and duplication anomalies of the EAC. Three patients had non-syndromic unilateral aural atresia and presented with periauricular lesions originating from the first branchial cleft. The other patient had a variant of Treacher Collins syndrome and presented with draining infra-auricular fistulae.

The classification and management of first branchial cleft anomalies is reviewed in light of these cases. An understanding of the embryogenesis of the external ear is necessary to successfully recognize and treat this spectrum of deformities. A classification system is presented that encompasses the full spectrum of first cleft anomalies.

Otomycosis usually requires long-term treatment and tends to recur. This study was performed on 87 patients with the clinical diagnosis of otomycosis and 20 controls in order to determine the pathogenic agents, predisposing factors and a cost-effective treatment. The predisposing factors included wearing head clothes (74.7 per cent), presence of dermatomycoses (34.5 per cent) and swimming (27.6 per cent). The most common pathogenic fungus was Aspergillus niger (44.8 per cent) in the otomycosis group. The only isolate was Candida albicans in the control group (2.5 per cent). We concluded that administration of four per cent boric acid solution in alcohol and frequent suction cleaning of the ear canal might be a cost-effective treatment for otomycosis since 77 per cent of the patients were treated effectively this way. Eighty per cent of the resistant cases had mixed fungal-bacterial infections, and 50 per cent of them had dermatomycoses. These resistant cases were treated by administration of tioconazole ointment.

In this multicentre, multinational, comparative, double-blind clinical trial, out-patients with both symptoms and radiographic evidence of acute sinusitis were randomly assigned to receive either a seven-day, once daily (o.d.) oral regimen of moxifloxacin (400 mg) or a 10-day o.d. oral regimen of trovafloxacin (200 mg). Among 452 patients considered valid for clinical efficacy, moxifloxacin treatment was found to be statistically equivalent to trovafloxacin (96.9 per cent vs 92.1 per cent -95 per cent CI = 0.6 per cent; 8.9 per cent) at the seven to 10 days post-therapy assessment. At follow-up, the success rate in the moxifloxacin group was 94.9 per cent and that for the trovafloxacin group was 97.6 per cent (95 per cent CI = -4.9 per cent; 1.3 per cent). The predominant causative organisms were Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus followed by Enterobacteriaceae and Moraxella catarrhalis. The bacteriological success rate at the post-therapy evaluation was similar in both treatment groups: 94.4 per cent and 90.1 per cent in the moxifloxacin and trovafloxacin groups respectively (95 per cent CI = −3.0 per cent; 11.9 per cent). Only three of the 103 baseline isolated pathogens still persisted in the moxifloxacin group, whereas there were 10 of the 121 isolates that failed to respond in the trovafloxacin treatment group. At least one drug-related event was reported by 16.9 per cent of the moxifloxacin-treated patients and by 22.3 per cent of those who received trovafloxacin. CNS events such as dizziness and vertigo were reported more than five times more often in patients receiving trovafloxacin than in the moxifloxacin group. Trovafloxacin recipients were also more than twice as likely to discontinue treatment due to adverse events than moxifloxacin-treated patients. Overall, moxifloxacin was at least as effective clinically and bacteriologically as trovafloxacin and better tolerated.

The aim of this study was to assess the success of the technique of open septoplasty with bipedicled flaps in achieving long-term closure and control of symptoms. Between 1993 and 2000, 32 patients underwent surgery for nasal septum perforation. Twenty patients with large perforations underwent posterior edge repair only. The remaining 12 patients (five female, and seven male) with perforations less than 20 mm in diameter underwent open septoplasty and a unilateral bipedicled flap closure. A retrospective review involving a symptom scores assessment and follow-up examination was conducted. One patient died of unrelated illness, and was excluded. Results showed 10 of the remaining 11 patients achieved closure after a mean follow up of 10 months. The symptoms of crusting (p < 0.0001), epistaxis (p < 0.02), discharge (p < 0.012), whistling (p < 0.011), and overall discomfort (p < 0.02), were all significantly improved. We conclude that by using this technique on patients with small perforations less than 20 mm, it is possible to achieve up to a 90 per cent perforation closure rate, and a significant improvement in patients’ symptoms.

A study was undertaken to determine whether the Provox® voice prosthesis provides good voice rehabilitation following a total laryngectomy in the urban, suburbanand rural populations served by a tertiary referral hospital in South Africa.

Between 1995 and 1999, a cohort of 128 patients at Tygerberg Hospital was rehabilitated with the Provox™ voice prosthesis after laryngectomy. In 104 patients primary placement of the prosthesis was done at the time of the laryngectomy. Mean device life and adverse events were determined. Voice quality was assessed subjectively in 104 patients and objectively in 26 patients.

The mean device life was 303 days and adverse events occurred in 16 patients. Subjectively, 77 of 104 patients had a good voice, and objectively 22 of 26 patients had good voice intelligibility. The Provox® voice prosthesis provides good voice rehabilitation following total laryngectomy, with minimal complications, in the population served by Tygerberg Hospital.

The development of hypertrophic mucosa and granulation tissue around a tracheo-oesophageal fistula voice prosthesis is a commonly encountered problem occurring in 15–20 per cent of patients. Upsizing of the voice prosthesis as well as cautery (silver nitrate and electocautery) are used to counteract this problem to a varying degree of success. The use of the CO2 laser has been mentioned by some authors but details of the method and results have not been published. We report the successful use of the KTP laser for removing such granulations whilst retaining the valve and discuss the reasons why this method should be considered.

Management of patients with carcinoma of the larynx should systematically include an appropriate treatment of lymph nodes according to the TNM stage. One of the most controversial points of the treatment in these patients is the management of the clinically negative neck (N0). A retrospective study of 295 patients with laryngeal carcinoma and N0 neck undergoing treatment in our centre between 1983 and 1993 is presented. We observed a significant decrease in the survival of clinically N0 patients with histologically affected lymphnodes. Lymphadenopathy was more frequently detected in patients with supraglottic tumours (38 per cent) when compared to glottic tumours (16 per cent). In our experience, routine bilateral and unilateral dissection of N0 necks in all supraglottic tumours and in T3–T4 glottic tumours, respectively, is the most beneficial approach for patients in terms of survival.

Endaural incisions provide a cosmetic approach to the middle-ear cleft, tympanic membrane for myringoplasty, and attic and antrum for small cavity mastoidectomy. These wounds have traditionally been closed with sutures, but platelet or fibrin adhesives provide an alternative. However, discomfort at the time of suture removal, particularly in children, and the risk of transmission of blood-borne infections in gels are limitations to these wound closure techniques. This paper describes our experience with Histoacryl® glue (butyl-2-cyanoacrylate) in closing endaural incisions.

The diagnosis and management of a patient with a sloughing otitis externa thought to be necrotizing fasciitis is described. The clinical characteristics of this condition, diagnostic difficulties faced and a brief literature review are presented.

The current incidence of missile injury to the temporal bone (MITB) is very low in the United Kingdom. However, the increasing frequency of firearm violence in Britain suggestsa greater risk of occurrence. This, along with the devastating potential sequelae of MITB (facial palsy, dead ear, intracranial damage, major vascular injury and cosmetic disfigurement), requires otolaryngologists to be conversant with all aspects of their management. The risk of major complications is much higher with MITB than with temporal bone injury following blunt trauma, and surgical management is, therefore, much more common. We present one such case, and review the literature outlining the pathogenesis, clinical features, and recommended management.

We report here the case of an epithelioid haemangioendothelioma (EHE) arising in the nasal cavity which is, to the best of our knowledge, the first ever described example in the world literature in that particular site.

The patient is a 23-year-old male who presented with repeated episodes of epistaxis from the nasal cavity and with a 1.5 cm reddish, polypoid, smooth, spontaneously bleeding nodule in the rightmiddle meatus. This lesion was histologically diagnosed as epithelioid haemangioendothelioma. Immunohistochemically the neoplasm displayed striking positivity for CD31, CD34 and vimentin. A surgical approach was performed by ’facial degloving’, removing the right inferior turbinate, the anterior two-thirds of the middle turbinate and the medial wall of the ethmoid bone. After 12 months follow-up the patient is disease-free, without any local or distant recurrence.

Permanent dysphagia occurring after laryngectomy or laryngopharyngectomy is uncommon, and when it does occur, can usually be treated by periodic dilatation under general anaesthesia. Occasionally, however, conservative treatment is insufficient, and patients require long-term feeding via a gastrostomy or jejunostomy tube. We describe the case of a man with an anastamotic stricture post-pharyngectomy who underwent insertion of a nitinol stent across the stricture for treatment of dysphagia. The patient’s swallowing was significantly improved in the short-term, however, ultimately, florid granulation tissue formation led to obstruction of the stent and a disappointing long-term result. This, to our knowledge, is the first documentation of the use of a stent to treat dysphagia in a patient post-laryngectomy or pharyngolaryngectomy.

Rehabilitation of voice and speech after laryngectomy with valve prosthesis has become a well-established practice in recent years. The formation of tracheo-oesophageal fistula (TOF) and the subsequent management of the patient with a voice prosthesis can be associated with a number of problems and complications.

We report a new technique of the use of injectable Bioplastique® in the treatment of persistent leakage around Provox® 2 voice prosthesis. Our experience in two cases has shown that it is a relatively simple and effective procedure in stopping the leak around the valve immediately and is without any short-term complications.

We report a case of tracheal stenosis in which a migrated Polyflex (Rusch AG, Germany) stent entered the right main bronchus but could not be identified on the chest radiograph. The stent was identified at bronchoscopy and removed under general anaesthesia.

Polyflex stents are radiopaque but may not always show up on radiograph. We recommend reliance on clinical symptoms rather than imaging to diagnose migration. If stent migration is suspected then imaging should include thoracic inlet films that incorporate a lateral view.

It is well known that in advanced cervical metastatic disease of head and neck squamous cell carcinoma, the incidence of distant metastasis is high. A case of distant metastasis to the scapular muscles from an uncontrolled cervical metastasis of laryngeal carcinoma is presented. Other unusual metastatic sites are reviewed and the possible mechanism of the spread is discussed.