In an environment of clinical governance with increased demands for accountability it is very important that accurate, reliable and secure data records be maintained for easy retrieval, analysis and presentation when required. A database is a very versatile tool for this purpose. We describe here our experience in designing a database for cochlear implant patients in Cambridge, together with guidance for prospective designers in their chosen sub-speciality.

In the last few years, the main thrust of research into cochlear implantation has centred around the development of advanced multi-channel implants. A new area of development is now concentrating on maximizing the potential of each individual electrode in order to improve the quality of hearing. This study involved the medialization of the cochlear implant electrode array using a silastic positioner in five patients. Two parameters were measured, namely current units needed to produce a stapedial reflex, and impedance levels between the electrode and modiolus. On insertion of the cochlear implant, readings were taken before the insertion of the positioner, immediately afterwards and at two months.

The otolaryngologist who requests magnetic resonance imaging (MRI) scans to exclude cerebellopontine angle (CPA) tumours may discover incidental pathologies. We retrospectively reviewed the results of 644 consecutive MRI screening scans with the aim of identifying findings other than CPA tumours. Two hundred and eighty-nine (45 per cent) scans featured one or more anomalies or abnormalities, including CPA tumour (23, four per cent), vascular loop (30, five per cent), basilar artery ectasia (13, two per cent), multiple high signal areas (135, 21 per cent), brain atrophy (52, eight per cent), sinus findings (56, nine per cent), middle ear/mastoid disease (34, five per cent), and a variety of other findings (39, six per cent) including clinically serious lesions (11, two per cent). The significance and management of these incidental findings is discussed. The majority were not clinically significant but the occasional presence of a serious incidental pathology should be borne in mind. Basilar artery ectasia and multiple high signal areas may be responsible for the symptoms investigated by MRI, and screening for cerebrovascular disease risk factors in such patients may be appropriate.

Case details were reviewed from 2021 patients treated surgically for nasal polyposis between 1991 and 1999, seen by six surgeons serving a catchment population of 805 000. The aim of this study was to determine the incidence of discrepancies between clinical and histological diagnosis. Twenty-two patients (1.1 per cent) were identified as having a lesion that differed histologically from the clinical diagnosis made at the time of surgery and which altered their further management. Amongst them were 11 cases of inverted papilloma, two of Wegener’s granulomatosis, and two of sarcoid. The rest of the cases comprised three of squamous cell carcinoma, one of adenocarcinoma, one of myeloma, one of angiofibroma and one of microcystic papillary adenoma. In this series, the occurrence of malignancy, inverted papilloma, or other clinically significant pathology among the group of patients with otherwise clinically unsuspected histology justifies sending nasal polyps for routine pathologic examination. A cost–benefit analysis showed that, on the basis of 250 cases per year, the cost of laboratory and pathological services would be £12.000, in comparison with the estimated average medicolegal cost of £51.000 per year incurred as a result of a delay in diagnosis together with the pain and suffering which would result given the case mix in this series.

The uncertain results of aryepiglottopexy in our personal experience led us to develop, for patients with aspirations associated with the risk of severe pneumonitis, three types of intralaryngeal endoprostheses (ILEP) under the systematic cover of a tracheostomy. From September 1997 to May 1999, seven protheses were implanted in six patients. It was not possible to restore the full range of laryngeal functions, i.e. deglutition, phonation and respiration. However, our results, that were obtained with an intracricoidal prothesis closed at its upper end or equipped with a phonatory valve, are quite encouraging, even more so when in association with early alimentary re-education and support continuation of our trial. These ILEPs are simple to place, well tolerated, efficacious in preventing deglutition pneumonitis and easy to remove. Furthermore, the reversibility of this bloodless procedure facilitates the monitoring of a possible recovery of the laryngeal functions.

A prospective study was undertaken in 75 patients with peritonsillar abscess to determine the treatment that was most effective in relieving the excruciating pain associated with the condition. The patients were divided into three treatment groups: intravenous antibiotic, aspiration, and incision and drainage. The effect of treatment on pain was objectively assessed by serially measuring the upper to lower incisor distance and by giving the patient water to drink at regular intervals to determine the point at which swallowing was pain-free. The improvement of the mean upper to lower incisor distance 15 minutes after the initial treatment was five per cent in the intravenous antibiotic group, 38 per cent in the aspiration group, and 100 per cent in the incision and drainage group. None of the patients in the intravenous antibiotic group was able to swallow water two hours after the initial treatment. In the same time interval two patients (eight per cent) in the aspiration group and 23 patients (92 per cent) in the incision and drainage group were able to swallow water. The conclusion derived from this study is that incision and drainage is superior to intravenous antibiotic and aspiration in relieving the pain associated with peritonsillar abscess.

Ninety-two total laryngectomy cases were investigated with reference to post-laryngectomy fistula formation. Fistula was observed in eight cases (8.69 per cent). There were no statistically significant differences between the fistula group and the non-fistula group with regard to pre-operative tracheotomy, tumour differentiation, positive surgical margins, concurrent neck dissection, previous radiotherapy, T stage of the tumour, presence of extended hypopharyngeal mucosal excision, and placement of nasogastric tube. The only statistically significant positive association was found with primary pharyngeal myotomy. Myotomy was performed in six of the fistula patients and in two cases a technical error was observed. In these cases myotomy was performed adjacent to the edge of hypopharyngeal mucosa resulting in a weakened area of pharyngeal closure, possibly contributing to the fistula. This should be kept in mind and avoided at all costs during the performance of myotomy. Since it was not possible to find out any specific causal relationship with myotomy in four other cases, further studies are needed to establish the association of myotomy with pharyngocutaneous fistula.

Polymorphic epithelial mucin (PEM), the protein product of the gene muc-1, is a surface glycoprotein that is produced by a range of normal epithelial cells, but has been shown to be expressed at high levels in a range of adenocarcinomas. It has not been investigated extensively in head and neck related tissues, and not at all in head and neck squamous cell carcinomas (HNSCC). This immunohistochemical investigation using two monoclonal antibodies to muc-1 represents a baseline study of 18 HNSCC. In 13 cases, the glycoprotein was expressed at varying levels, usually in keratinizing foci. Although less prominent, expression was also present to some degree in nine of 23 control specimens of non-neoplastic mucosa, mostly at an epithelial level early in the parakeratinization process. Both antibodies showed a pattern of staining. The cellular basis for muc-1 expression is speculative at present and although it is at a lower level than in adenocarcinomas, it may help to provide further insight into epithelial cell differentiation in squamous cell carcinomas.

This paper demonstrates the need for a cosmetic device as a necessary adjunct to long-term tracheostomy care. Such devices are not available, at present, from tracheostomy tube manufacturers. The cosmetic tracheostomy cover plate is based on a silver Negus tracheostomy tube, to which the silver chain and cover plate (locket) are attached. The result, for the patient who tried it, was excellent.

Congenital cholesteatoma may arise in the petrous apex, mastoid, middle ear, or external auditory canal. The least common site being the mastoid process. We present one case of primary mastoid cholesteatoma confirmed by clinical examination, surgical findings and radiological evaluation.

Controversy exists concerning stapedotomy for patients with small unilateral air-bone gaps. Surgical treatment of otosclerosis involves an opening to the labyrinth and accordingly, a risk of complications, usually vertigo and sensorineural hearing loss and infrequently anacusis. In this paper we present a 33-year-old woman with a small unilateral air-bone gap, who developed bacterial labyrinthitis with meningitis and anacusis three days after stapes surgery. The patient had a stapedotomy with the small fenestra piston prosthesis technique. Due to the potential for serious complications, patients with unilateral otosclerosis and mild hearing loss should be given the possibility to choose between a hearing aid and surgery. Although stapedotomy in the vast majority of interventions is a highly successful procedure and the best method of treatment for otosclerosis if successful, there is a high price to pay in the event of failure.

The incidence of an aberrant internal carotid artery in the middle ear is approximately one per cent and most patients are asymptomatic. We present two patients with an aberrant internal carotid artery who presented with pulsatile tinnitus and an intra-tympanic mass. Here we discuss the clinical presentation, relevant radiographic investigations and further management of these patients.

This paper reports a case of spontaneous indirect carotid cavernous fistula that presented with pulsatile tinnitus, left-sided temporal headache and left-sided ptosis. The pulsatile tinnitus, its aetiology and investigation are discussed. The importance of pulsatile tinnitus is highlighted, with a discussion of carotidcavernous fistulas. This case illustrates that clinically silent cavernous sinus thrombosis can give rise to spontaneous indirect carotid cavernous fistula. Magnetic resonance imaging angiography was used in diagnosis. Treatment ranges from observation, as in our case, to transvenous endovascular techniques.

Functional laryngeal dyskinesia is a disorder that presents with stridor. Failure to recognize its features can result in inappropriate investigation and treatment for a condition that has a psychogenic origin. The key feature in diagnosis is paradoxical vocal fold adduction on inspiration, as seen on fibre-optic nasendoscopy. This phenomenon together with the associated stridor may disappear after distraction techniques or when the patient is asleep. We present five such cases which presented to hospitals in south west London over a 12 month period.

A case of an 87-year-old female with pleomorphic adenoma of the tongue base is reported, with a review of the literature. The tumour had enlarged gradually over a period of three years, causing dysphagia and dysphasia. Computed tomography and magnetic resonance imaging showed that the tumour was exophytic and occupy the oropharynx with little extension into the muscle tissue. The tumour was resected by CO2 laser. Histological examination revealed a benign pleomorphic adenoma that originated from the minor salivary gland of the tongue base.

In this case a secondarily infected pseudoaneurysm of the common carotid artery presented with clinical features suggestive of a parapharyngeal abscess. The causative organism was identified as community-acquired methicillin-resistant Staphylococcus aureus. To the authors’ knowledge this condition not previously been reported.

Cerebral venous sinus thrombosis is an uncommon but potentially lethal condition, with mortality between 5.5–30 per cent. It was previously associated with infections of the orbit, mastoid or face, but, after the advent of antibiotics, the most common causes include neoplasms, dehydration, oral contraceptives, coagulopathies, collagen diseases, and pregnancy and the puerperium. We report a case of fatal cerebral venous sinus thrombosis in a 68-year-old patient with a metastatic cervical mass, who developed internal jugular vein thrombosis that progressed cranially to transverse and sagittal sinus thrombosis.

A bilobed pharyngeal pouch is a very rare finding. One such case is reported here, and is the first to be treated successfully by endoscopic division and stapling.