(1) To identify newly diagnosed cases of methicillin-resistant Staphylococcus aureus ear infection in our local population; (2) to determine the risk factors involved in these patients' clinical courses, and (3) to type the bacterial strains isolated and thus identify whether they were hospital- or community-acquired.

Retrospective review of case notes, together with laboratory-based molecular studies in the departments of otolaryngology and medical microbiology in a university teaching hospital in Scotland, UK.

Over a two-year period, 35 patients were identified with ear swabs positive for methicillin-resistant Staphylococcus aureus infection. These cases came from both hospital and community settings.

(1) Identification of primary methicillin-resistant Staphylococcus aureus otorrhoea in patients with no previously documented colonisation; and (2) molecular typing of the strains isolated, using spa technology, to identify whether they were hospital- or community-acquired.

Of the 35 positive patients, 27 were previously known carriers of methicillin-resistant Staphylococcus aureus. The eight patients with newly diagnosed methicillin-resistant Staphylococcus aureus otorrhoea presented initially in the community. All of these patients had had contact with hospital staff (as in-patients or out-patients) in the weeks preceding development of their ear infection. Using the spa technique for molecular typing, we identified hospital-acquired (‘epidemic’) methicillin-resistant Staphylococcus aureus type 15 in all eight patients' isolates. All were sensitive to topical gentamicin.

In our cohort, hospital-acquired methicillin-resistant Staphylococcus aureus type 15 was the commonest cause of methicillin-resistant Staphylococcus aureus otorrhoea, despite the fact that these patients all first presented in the community. We believe that contact with hospital staff or health care workers is a risk factor for acquiring methicillin-resistant Staphylococcus aureus otorrhoea in the community.

To establish normative dimensions for the depth of the olfactory fossa, the length and angulation of the lateral lamella of the cribriform plate, and the height of the ethmoid roof, in adult males and females.

The study assessed 300 high resolution, multislice computed tomography scans of the paranasal sinuses, which were evaluated using Merge Efilm software (version 2.0.0, build 37).

According to the original Keros classification, the type II olfactory fossa was the commonest type in men (66.7 per cent), while the type I fossa was commonest in women (53 per cent). A difference of 3 mm or more between the depths of the right and left olfactory fossae was present in 11 per cent of men and 2 per cent of women. The lateral lamella of the cribriform plate was significantly shorter and less oblique in men than in women. The length of the lateral lamella was greater anteriorly than posteriorly in both sexes. There was a statistically significant difference between the angle of the lateral lamellae, comparing right and left sides. The ethmoid roof was lower in women than men.

The observed differences between men and women and between the right and left sides are of surgical importance, and should alert surgeons to the need for thorough, systematic pre-operative evaluation of computed tomography scans.

This study aimed to review cases of Lemierre's and Lemierre's-like syndromes in paediatric patients, to examine a possible association with Epstein–Barr virus as a predisposing factor, and to assess the impact of this virus on the severity of illness.

We performed a retrospective analysis of data from the in-patient database at Winthrop University Hospital, from January 2001 to October 2007. We reviewed clinical and laboratory findings as well as the outcome of infection in patients aged 21 years or less with a diagnosis of Lemierre's syndrome. An additional case of Lemierre's-like syndrome was also included. The illness severity and duration of in-patient management of those testing positive for heterophile antibody were then compared with the same parameters in patients who tested negative.

Of the five patients diagnosed with Lemierre's syndrome, two had concomitant acute infection with Epstein–Barr virus. Additionally, a 19-year-old adolescent was admitted during this period with acute infectious mononucleosis, Fusobacterium necrophorum sepsis, sinusitis, frontal lobe abscess and ophthalmic vein thrombosis. The clinical presentation of all patients included fever, sore throat, and ear or neck pain. The duration of symptoms ranged from two days to three weeks prior to admission. The patients with acute Epstein–Barr virus infection had been diagnosed with infectious mononucleosis prior to admission, and tested positive for heterophile antibody. These patients subsequently underwent more extensive in-patient treatment, including intensive care management and ventilator support. The patients who tested negative for heterophile antibody experienced a milder course of illness, with a shorter duration of in-patient management.

Two patients diagnosed with Lemierre's syndrome, and a third with Fusobacterium necrophorum sepsis, had coexisting acute Epstein–Barr virus infection. Patients who tested positive for heterophile antibody experienced a more severe course of illness. These observations suggest a possible association between Epstein–Barr virus infection and the severity of concomitant Lemierre's syndrome.

This study aimed to assess the feasibility of using a 1.3 mm, semi-rigid, interventional salivary endoscope for middle-ear endoscopy, and as a trans-tympanic route for delivery of medication, in human cadaveric temporal bones.

Human cadaveric study.

Five temporal bones harvested from human cadavers were examined. A 1.3 mm, interventional sialendoscope was used to make endoscopy-assisted myringotomy incisions in the postero-inferior quadrant (n = 5) and the antero-inferior quadrant (n = 3).

Middle-ear examination was successful in all specimens (n = 5). Access to the round window niche and adequate visualisation of the round window were achieved in all five temporal bones (100 per cent). A guide wire could be navigated to the round window niche without difficulty. Other structures identified in all specimens included the incudostapedial joint, stapedius tendon, pyramidal eminence and facial nerve via an extended myringotomy incision. The anterior middle-ear space was also successfully examined through an endoscope-guided anterior myringotomy. The opening to the eustachian tube was visualised and cannulated with a guide wire in all preparations in which this was attempted (n = 3).

The 1.3 mm, interventional sialendoscope allowed adequate visualisation of the eustachian tube, middle-ear space and round window niche, with interventional capabilities, in a cadaveric model. Our result validates the feasibility of its use for trans-tympanic drug delivery.

Impaired cochlear perfusion appears to be the most important event in the development of sudden sensorineural hearing loss. Methylenetetrahydrofolate reductase gene mutations at nucleotide 677 cause reduced methylenetetrahydrofolate reductase enzyme activity, resulting in vascular impairment.

Thirty-three patients and 68 control subjects underwent audiological and haematological investigation.

No statistically significant association was found between sudden sensorineural hearing loss and the methylenetetrahydrofolate reductase C677T gene mutation. Mean homocysteine and cholesterol concentrations were significantly higher in patients than in controls. Mean folate levels were significantly lower in patients than in controls. Amongst patients with sudden sensorineural hearing loss, no significant differences in mean cholesterol, homocysteine or folate concentration were found, comparing patients with methylenetetrahydrofolate reductase C677T mutation genotypes with those without.

No statistically significant association was found between the methylenetetrahydrofolate reductase C677T gene mutation and sudden sensorineural hearing loss. There was a statistically significant difference between the homocysteine, folate and cholesterol concentrations of sudden sensorineural hearing loss patients, compared with controls. However, there was no statistically significant difference in these levels, comparing patients with and without the methylenetetrahydrofolate reductase C677T mutation.

To compare the use of computed tomography – positron emission tomography and whole-body magnetic resonance imaging for the staging of head and neck cancer.

From January to July 2009, 15 consecutive head and neck cancer patients (11 men and four women; mean age 59 years; age range 19 to 81 years) underwent computed tomography – positron emission tomography and whole-body magnetic resonance imaging for pre-therapeutic evaluation. All scans were staged, as per the American Joint Committee on Cancer tumour–node–metastasis classification, by two blinded consultant radiologists, in two sittings. Diagnoses were confirmed by histopathological examination of endoscopic biopsies, and in some cases whole surgical specimens.

Tumour staging showed a 74 per cent concordance, node staging an 80 per cent concordance and metastasis staging a 100 per cent concordance, comparing the two imaging modalities.

This study found radiological staging discordance between the two imaging modalities. Whole-body magnetic resonance imaging is an emerging staging modality with superior visualisation of metastatic disease, which does not require exposure to ionising radiation.

This study aimed to evaluate a single institute's experience with resection of metachronous pulmonary malignancy in patients treated for squamous cell carcinoma of the head and neck.

Sixty-three consecutive patients treated curatively for head and neck squamous cell carcinoma underwent surgical resection of malignant lung lesions. Survival was estimated and potential prognostic factors investigated.

The median overall survival for the total group was 22.2 months. Fifty-one patients (81 per cent) had one lung lesion, while the remainder had multiple lesions (range, two to seven). In the 63 patients, 35 lobectomies, 4 pneumonectomies and 24 wedge resections were performed. For patients with pulmonary squamous cell carcinoma (n = 52), the three-year survival rate was 35 per cent (95 per cent confidence interval, 22–48); for patients with resected adenocarcinoma (n = 10), it was 50 per cent (95 per cent confidence interval, 18–75). The overall five-year survival rate was 30 per cent (95 per cent confidence interval, 19–42).

In patients treated curatively for head and neck squamous cell carcinoma, resection of secondary pulmonary cancer is associated with favourable long term overall survival, especially for patients with adenocarcinoma lesions.

This study aimed (1) to investigate the relationship between the presence of lymph node central necrosis, viewed on pre-operative computed tomography imaging, and the occurrence of histopathologically determined metastatic lymph node extracapsular spread and (2) to determine whether a larger scale study would be valuable.

Pre-operative computed tomography scans, surgical records and post-operative histopathological analysis results were reviewed for 19 consecutive neck dissections performed in 17 patients with head and neck squamous cell carcinoma.

A total of 20/26 (77 per cent) lymph nodes with central necrosis had extracapsular spread on histopathological analysis. Twenty of 21 (95 per cent) lymph nodes with extracapsular spread had central necrosis on pre-operative computed tomography. Thirty-four of 40 (85 per cent) lymph nodes without extracapsular spread had no evidence of central necrosis on computed tomography. Only three of 12 (25 per cent) patients with lymph node central necrosis identified on pre-operative computed tomography were found to have actual necrosis on final histopathological analysis.

Lymph node central necrosis viewed on pre-operative computed tomography scans is a useful indicator of metastatic lymph node extracapsular spread, with a sensitivity of 95 per cent, a specificity of 85 per cent, a positive predictive value of 69 per cent and a negative predictive value of 98 per cent. Lymph node diameter is not a sensitive indicator of extracapsular spread.

Parotidectomy in children is uncommon, and surgeons face specific challenges not encountered in adult practice.

Retrospective review of parotidectomies performed in our paediatric hospital over a 10-year period (1999–2008).

Twenty-one children underwent 22 parotidectomies, of which six were total. The following pathology was encountered: atypical mycobacterial infection (8.38 per cent), pleomorphic adenoma (4.19 per cent), lymphatic malformation (2.10 per cent), haemangioma (2 per cent), first branchial cleft anomaly (2 per cent), follicular non-Hodgkin's lymphoma (2 per cent) and lipoblastoma (1.5 per cent). No cases of permanent facial nerve palsy occurred. Mild transient facial nerve palsy occurred in five patients (23 per cent), gustatory sweating in four (19 per cent) and hypertrophic scarring in three (14 per cent).

We discuss the range of parotid pathology found in children, the approach to investigation, the surgical difficulties encountered, and ways to reduce the apparently higher rate of complications encountered. Parotid surgery in children should be concentrated in the hands of a small number of surgeons with a particular interest in this area.

To present our experience in managing cerebrospinal fluid rhinorrhoea using the cartilage inlay (underlay) technique to repair skull base defects larger than 4 mm.

Retrospective study involving patients presenting with cerebrospinal fluid rhinorrhoea between 1994 and 2008.

Patients were treated in a tertiary referral centre for nose and sinus diseases. Patients' medical records were reviewed and analysed.

A total of 62 patients were operated upon using a cartilage inlay technique to repair bony skull base defects ranging in size from 4 to 20 mm (widest diameter). Of these 62 patients, 16 constituted revisions of earlier procedures undertaken elsewhere. The success rate of the technique was 100 per cent. Patient follow up ranged from six months to 16 years, with a median follow up of 15 months. Three patients had minor post-operative sinus infections; no serious complications were encountered.

Extradural cartilage inlay appears to be an effective technique in the management of cerebrospinal fluid rhinorrhoea, especially for large defects and revision procedures. To our knowledge, the described patients represent the largest reported series of cerebrospinal fluid rhinorrhoea cases managed using the cartilage inlay technique. We believe that the crucial factors in our high success rate for cerebrospinal fluid fistula repair are: precise identification of the bony defect; meticulous preparation of the graft bed; careful elevation of the dura; judicious use of just enough graft tissue; and adequate graft support.

There is a clear clinical need to reliably detect residual cholesteatoma after canal wall up mastoid surgery. Ideally, this would be achieved through non-invasive radiological means rather than second-look surgery, thus preventing morbidity in those patients in whom no residual disease is found.

We describe a case in which non-echo-planar, diffusion-weighted magnetic resonance imaging sequences were used pre-operatively, and compared with subsequent surgical findings. This case highlights both the potential of this increasingly popular magnetic resonance technique and also its current limitations.

Various magnetic resonance sequencing types have been employed to try to reliably detect residual cholesteatoma, each with varying success. Non-echo-planar, fast-spin echo, diffusion-weighted sequences currently appear to be the most reliable at detecting even the smallest pearl of cholesteatoma, down to 2 mm in diameter. In our unit, a propeller, diffusion-weighted image sequence is employed on a GE Signa scanner. However, both this case study and other reports show that the accuracy of the technique is not 100 per cent. This begs the question of how much one can rely on the findings of such techniques when deciding whether second-look surgery is indicated. Scan-negative patients will require continued follow up as, at the time of imaging, residual disease may not have reached a detectable size.

Jugular foramen schwannomas are rare skull base tumours which typically have a variable clinical presentation. Glossopharyngeal syncope syndrome is an unusual clinical presentation; in the following case report, it was the sole presentation of an extracranial jugular foramen tumour.

The presentation of a patient with glossopharyngeal neuralgia syncope syndrome is reviewed and the pathophysiology, clinical features and treatment discussed.

A 45-year-old woman presented with unilateral throat pain, bradycardia and hypotension leading to episodes of impaired consciousness when lying on her left side or turning her head to the left. Imaging detected a left-sided extracranial jugular foramen schwannoma. The tumour was excised, and the patient had no more syncopal attacks.

Glossopharyngeal neuralgia syncope syndrome can be the sole presentation of a jugular foramen schwannoma. Although this syndrome may be treated with anti-dysrhythmic drugs, cardiac pacing or nerve section, in the presented patient excision of the jugular foramen schwannoma was successful in preventing further episodes of syncope.

We report a rare case of a nasal glioma found incidentally in an adult, presenting with visual loss, optic nerve oedema and proptosis.

A 41-year-old woman presented with bilateral proptosis, impairment in visual acuity (6/60 bilaterally) and loss of colour vision. Computed tomography and magnetic resonance imaging showed proptosis, bilateral optic nerve swelling and a heterogeneous mass occupying the left nasal cavity and extending through a skull base defect into the anterior cranial fossa. Biopsy confirmed a nasal glioma. Treatment with intravenous dexamethasone resolved the proptosis, and the patient's visual acuity recovered to 6/9 bilaterally. At the multidisciplinary team meeting, it was felt that the nasal glioma probably represented an incidental finding and was not directly responsible for the patient's proptosis and transient visual loss.

To our knowledge, this is the first report in the English language literature of adult nasal glioma presenting with visual loss. The management of nasal gliomas in adults is contentious and the relevant literature is reviewed. This case was managed conservatively with regular follow up.

A patients with undiagnosed type II diabetes mellitus presented with infective rhinocerebral mucormycosis.

Initial magnetic resonance imaging scans demonstrated an aggressive disease process involving the left orbit and paranasal sinuses. A repeated scan following treatment excluded intracranial spread or recurrence. Pus from the paranasal sinuses grew Rhizopus arrhizus on microbiological culture.

Initial treatment comprised intravenous liposomal amphotericin B, intravenous co-amoxiclav and surgical debridement. The patient's diabetes was managed medically. The development of drug-induced transaminitis required a change of medication. The dose of liposomal amphotericin B was reduced, and then titrated back up as the liver function test results improved. Posaconazole was also introduced and the patient was eventually discharged on this alone, as the maximum recommended cumulative dose of liposomal amphotericin B had been reached.

Posaconazole may be used effectively in conjunction with surgical debridement in the treatment of patients with infective rhinocerebral mucormycosis who develop hepatotoxic side effects to liposomal amphotericin B. Posaconazole may also allow a reduction in the dose of liposomal amphotericin B, resulting in better tolerance.

We report a rare case of avascular necrosis of the maxilla secondary to oral bisphosphonates.

Case report and review of the world literature concerning avascular necrosis as a result of bisphosphonate therapy.

A 62-year-old woman presented with unilateral nasal obstruction, swelling of the cheek and an ulcerating lesion of the upper alveolus. She had a past medical history of osteoporosis, for which she took oral bisphosphonates. Investigation revealed necrosis of the maxilla, and avascular necrosis secondary to oral bisphosphonates was diagnosed.

There have been several documented cases of avascular necrosis of the mandible and maxilla following intravenous bisphosphonates or dental procedures. In our case, bisphosphonates were only taken orally and no dental work had been undertaken. This patient's clinical presentation was highly suggestive of malignancy, and we would like to communicate this unusual case to other otolaryngologists.

We report two cases of plastic bronchitis presenting with acute respiratory failure and mimicking foreign body inhalation.

The clinical findings, differential diagnoses and radiological investigation are discussed.

Plastic bronchitis is an uncommon condition, particularly in children. The condition may present to otolaryngologists with symptoms mimicking foreign body inhalation. It is important to consider plastic bronchitis as a differential diagnosis, based on its clinical and radiological signs. Early intervention, in the form of bronchoscopy, can be both diagnostic and therapeutic.

Plastic bronchitis is uncommon and its clinical and radiological features are non-specific. The recommended management is early bronchoscopy to establish the diagnosis and enable therapeutic intervention.

Neck abscesses can originate from congenital cervical cysts. Cervical cysts of bronchogenic origin are rare and often asymptomatic. Common symptoms of bronchogenic cysts are stridor, dyspnoea and dysphagia. The reported patient represents the second published case of a bronchogenic cyst causing a neck abscess in an adult.

We report a case of a cervical bronchogenic cyst presenting as a recurrent supraclavicular abscess in a middle-aged woman. During extirpation, a fistula was demonstrated to the right upper lobe of the lung, suspected because the cyst inflated synchronously with respiration.

The symptoms of bronchogenic cysts are due to the effects of compression or fistulas. In the majority of these cysts, a thorough investigation involving history, examination and radiological imaging does not clearly demonstrate a fistula. Therefore, extirpation is both diagnostic and therapeutic.

A bronchogenic cyst is a very rare cause of a recurrent deep neck abscess. Total extirpation is the treatment of choice.

To report our experience of using propranolol to treat an infantile airway haemangioma.

A five-week-old girl presented with upper airway obstruction. Having started systemic steroids, concurrent propranolol therapy was commenced. Propranolol was given with close monitoring of the blood pressure, pulse and capillary glucose level. The dose of propranolol was gradually increased to 2 mg/kg total daily dose, with simultaneous reduction and withdrawal of steroids.

Prior to propranolol treatment, laryngotracheobronchoscopy revealed an extensive haemangioma extending from the posterior pharyngeal wall to the subglottis. Following initiation of propranolol, a dramatic reduction in tumour bulk was seen on repeated laryngotracheobronchoscopy within 10 days of treatment. Eight months on, the patient remained asymptomatic on propranolol, with no endoscopic evidence of disease apart from mild telangiectasia.

Haemangiomas of the airway can cause obstruction which may potentially be life-threatening. This case demonstrates the potential of propranolol to become a valuable therapeutic option in such clinical situations.

The development of a tracheo-arterial fistula is a rare but severe complication of tracheotomy. The reported patient presented with such a fistula involving an aberrant right subclavian artery, termed an arteria lusoria, an aortic arch abnormality which is usually asymptomatic.

A 30-year-old man was admitted to our institution for bleeding through his tracheotomy. He had been treated for advanced Duchenne muscular dystrophy, involving invasive assisted ventilation, since the age of 10 years. Surgical exploration and computed tomography scanning revealed a tracheo-arterial fistula involving an aberrant right subclavian artery, associated with severe scoliosis. Emergency, transient haemostasis was achieved by over-inflation of the tracheostomy tube cuff. Aneurysm ablation was successfully achieved as the result of an endovascular interventional radiology procedure.

Arteria lusoria is one of the most common aortic arch abnormalities. The occurrence of an aneurysm of this artery in a tracheotomised patient has not previously been described. In Duchenne muscular dystrophy patients, spinal deformities may result in thoracic compression, which may alter the anatomical relations of mediastinal vessels. Such deformities are slowly progressive. Thus, vigilance is required in the long term management of Duchenne muscular dystrophy patients with a tracheostomy.