Decompression of the endolymphatic sac for Ménière's disease gives unpredictable results. This may be because the sac is difficult to identify and decompress accurately without causing surgical trauma.

In order to test this idea, transmastoid decompression was simulated in 5 cadaver half heads and the anatomy of the endolymphatic sac was reviewed in a further 14 specimens.

The endolymphatic sac was found and confirmed by histology in all five simulated decompressions. A newly described feature, a trapezoid thickening of dura, was a useful guide. The review showed that the sac was constant proximally, but variable distally. The posterior semicircular canal, posterior fossa dura and sigmoid sinus are at risk during dissection.

The endolymphatic sac may be identified on inspection by an overlying patch of dura, thereby reducing exploratory dissection. It is best to decompress the sac as far proximally as possible, whilst protecting the posterior semicircular canal.

Otic barotrauma is common among air travellers and can cause severe otalgia, perforation of the tympanic membrane and hearing loss. Many prevention measures exist, with varying evidence to support their use. There are no data to establish if air travellers are aware of them or indeed use them. We aimed to establish air travellers' knowledge of such prevention measures.

We surveyed air travellers at two UK airports by means of a questionnaire. Answers to the questionnaire were collected over a two-week period.

Overall, 179 air travellers with a mean age of 28 years (range: 15–72 years) completed the questionnaire. There were 66 female and 113 male air travellers. The majority (84 per cent) complained of symptoms while flying and 30 per cent were not aware of any prevention measures. Barotrauma-related symptoms were reported in 25 per cent of air travellers who were unaware of any prevention measures. Nearly all air travellers (86 per cent) indicated that more information regarding prevention measures would be useful.

Air travellers are often not aware of prevention measures to avoid otic barotrauma, and the majority suffer as a result. Increasing public awareness of simple prevention measures would have a significant impact on air travellers.

To compare chronic suppurative otitis media prevalence in rural and urban primary school children in Bangladesh, and to determine its relationship with specific sociodemographic factors.

In this cross-sectional survey, 681 rural primary school children from Shibpur upazilla, Narsingdi district, and 964 urban primary school children from Dhaka Metropolitan City, underwent an ENT check-up by doctors trained in ENT. Their parents or guardians were interviewed with regard to their sociodemographic status and other related issues using a pre-tested protocol.

In this study, 6.02 per cent of the rural primary school children and 2.07 per cent of the urban primary school children had chronic suppurative otitis media. (Overall, 3.71 per cent of the children had the disorder.) The disorder was slightly more prevalent among girls than boys in both rural (6.05 vs 5.98 per cent) and urban (2.33 vs 1.82 per cent) communities. There was a significant association between the presence of chronic suppurative otitis media in children and: parents' or guardians' occupation and their annual income, housing type, family size, maternal education, and bathing habit.

Improvement of associated sociodemographic factors would reduce the prevalence and resultant complications of chronic suppurative otitis media in primary school children in developing countries.

To compare the effect of right- or left-sided cochlear implantation on listening skills in a paediatric population.

A retrospective analysis was conducted on the listening skills performance data of children who were operated on and followed up at the Çukurova University Department of Otorhinolaryngology between 2007 and 2011. Sixty-three patients were included in the study. Patients were evaluated using the Listening Progress Profile, the Meaningful Auditory Integration Scale and the littlEARS test.

The mean age of the children was two years (range of one to five years). Twenty-nine patients were male and 34 were female. Twenty-eight patients were implanted in the right ear and 35 in the left ear. There were no statistically significant differences between right and left ear implantees in terms of listening skills performance.

This study indicates that the choice of cochlear implant side is not crucial for the development of listening skills.

Ear cartilage piercing is increasingly popular and has a significant complication rate. Contrary to popular belief, there are no minimum qualifications required to practice ear piercing. This study evaluated ear cartilage piercing practices in London, UK.

Practitioners at 25 piercing parlours completed a telephone questionnaire assessing piercing practice.

Ninety-six per cent of practitioners were aware of the risk of infection post-piercing. Four per cent, 12 per cent and 0 per cent of practitioners were aware of keloid scarring, hypertrophic scarring and cauliflower ear respectively. No practitioners were aware of any other complications. Their consent forms did not document any ear cartilage complications. Twenty-eight per cent of participants advised clients to seek medical attention following a complication. Forty per cent did not provide written post-piercing guidance.

Piercing practitioners were insufficiently aware of ear cartilage piercing complications. It is unlikely that informed consent was obtained prior to piercing. The post-piercing practice of the majority of parlours did not follow published national guidance.

To evaluate the outcomes (using validated outcome tools) and cost benefits of functional endoscopic sinus surgery in a population of severely asthmatic patients with chronic rhinosinusitis.

A prospective cohort study was conducted. The study comprised consecutive patients diagnosed with asthma and chronic rhinosinusitis for whom medical treatment had failed and who were scheduled for functional endoscopic sinus surgery. General health and disease-specific outcome questionnaires were completed pre- and post-operatively. Costs associated with both functional endoscopic sinus surgery and out-patient visits to a comprehensive asthma clinic were calculated.

A total of 47 patients completed the surveys. The average improvement in Chronic Sinusitis Survey scores following functional endoscopic sinus surgery was 17 per cent. The average reduction in out-patient asthma clinic visits was 50 per cent, which translates to an average cost saving of $1035 Canadian dollars per patient per year.

Functional endoscopic sinus surgery is a cost-effective treatment modality for asthmatic patients with chronic rhinosinusitis. This information is important for: the distribution and planning of resources, prioritising health programmes, and establishing practice guidelines.

Patients often present with facial pain ascribed to sinusitis, despite normal nasal endoscopy and sinus computed tomography. Facial pain is increasingly recognised to be of neurological origin.

A cohort of 240 patients with chronic facial pain was followed up for 36 months at an otolaryngological practice in Malta. The types of facial pain were classified according to International Headache Classification criteria. The body mass index, occupation and educational level of patients were compared with the general population.

Tension-type mid-facial pain and facial migraine without aura were the most common types of chronic facial pain. The sites of pain, symptoms, treatment and outcomes for these principal pain types are discussed. Patients with mid-facial pain were treated with low-dose amitriptyline for eight weeks. After three years, nearly half of the patients were symptom free, and in a third the pain changed from being chronic to being episodic. The treatment of patients with facial migraine was more varied but the length of time until recurrence of pain was similar.

The most effective long-term treatments for tension-type mid-facial pain and facial migraine were low-dose amitriptyline and low-dose amitriptyline and triptans, respectively.

Head and face dimensions vary according to race and geographical zone. Hereditary factors also greatly affect the size and shape of the head. There are important medical applications of craniofacial data specific to different racial and ethnic groups.

Various cranial and facial anthropometric parameters were assessed in singleton, healthy, full-term newborns of Sikkimese origin in a tertiary care hospital in Sikkim, India. The data were then analysed to determine statistically significant differences between sexes.

Forty-five newborns were included in the study. Both male and female newborns were observed to be hyperbrachycephalic and hyperleptoprosopic. The only significant difference between the sexes was in commissural length, which was observed to be greater in male newborns.

Craniofacial parameters in Sikkimese newborns vary in comparison with those of other newborns from around the world. Larger studies are needed in order to reveal sex-related variations. Similar studies on various racial groups in North-East India are needed to establish standards for populations with East Asian features.

Recurrent aphthous stomatitis is a common disease of the oral mucosa, affecting 20 per cent of the general population.1 However, the aetiology of this disease is unknown. This is the first controlled study to compare zinc levels in recurrent aphthous stomatitis patients with those of a well-matched, healthy, control population.

Twenty-five patients with a history of recurrent aphthous stomatitis and 25 healthy people (control group) took part in the study. Patients aged between 20 and 40 years with recurrent oral aphthous ulcers less than 1 cm in diameter were included. Exclusion criteria were pregnancy and lactation, systemic disease (ulcerative colitis, Crohn's disease, Behçet's disease), any current medication (topical or systemic), dental surgery during the previous month and deficiencies in iron, folic acid or vitamin B1, B2, B6 or B12. Serum zinc levels were compared between patient and control groups.

Zinc deficiency was detected in 28 per cent of recurrent aphthous stomatitis patients and in 4 per cent of controls. The mean serum zinc level in the patient group was significantly lower than in the control group.

These results suggest an association between zinc deficiency and recurrent aphthous stomatitis.

The non-recurrent laryngeal nerve is subject to potential injury during thyroid surgery. Intra-operative identification and preservation of this nerve can be challenging. Its presence is associated with an aberrant subclavian artery and the developmental absence of the brachiocephalic trunk. This study aimed to evaluate the incidence of non-recurrent laryngeal nerves and present a new classification system for the course of these nerves.

Non-recurrent laryngeal nerves were identified on the right side in 15 patients who underwent thyroidectomy. The incidence of non-recurrent laryngeal nerves (during thyroidectomy) and aberrant subclavian arteries (using neck computed tomography) was evaluated, and the course of the nerves was classified according to their travelling patterns.

The overall incidence of non-recurrent laryngeal nerves was 0.68 per cent. The travelling patterns of the nerves could be classified as: descending (33 per cent), vertical (27 per cent), ascending (20 per cent) or V-shaped (20 per cent).

Clinicians need to be aware of these variations to avoid non-recurrent laryngeal nerve damage. A retroesophageal subclavian artery (on neck computed tomography) virtually assures a non-recurrent laryngeal nerve. This information is important for preventing vocal fold paralysis. Following a review of non-recurrent laryngeal nerve travelling patterns, a new classification was devised.

To review the diagnosis of Munchausen syndrome by proxy, a factitious disorder, in which symptoms are induced or feigned, usually in a child, by the caregiver. The involved caregiver seeks to gain attention or sympathy and often has a psychological need to maintain the sick role. We highlight the diagnostic difficulties and factors that may help with diagnosis in an otolaryngology setting.

We present the case of Munchausen syndrome by proxy presenting with hearing loss in a five-year old boy, who was diagnosed eight years after his initial presentation. A literature review of Munchausen syndrome by proxy cases presenting with ENT symptoms is provided.

Munchausen syndrome by proxy is a diagnosis that otolaryngologists should be aware of, particularly where recurrent or persistent illnesses in children, especially those involving otological symptoms, are refractory to the usual treatments.

To report a case of meningioma arising from the nervus intermedius.

This paper comprises a case report, literature review, and discussion regarding the presentation of a nervus intermedius meningioma, comparing and contrasting this to other relevant neoplasms of the internal auditory canal and cerebellopontine angle.

Tumours of the cerebellopontine angle include vestibular schwannomas, facial schwannomas and, more rarely, nervus intermedius schwannomas. The nervus intermedius is a division of the facial nerve at the cerebellopontine angle, with parasympathetic and afferent somatic components. Our patient presented with progressive hearing loss. An ipsilateral internal auditory canal mass at the fundus, as indicated by magnetic resonance imaging and electroneuronography, was suggestive of vestibular schwannoma. Intra-operative dissection revealed a nervus intermedius tumour. Histological evaluation indicated a meningioma rather than a schwannoma.

This is the first reported case of meningioma involving the nervus intermedius. The implications this pathology may have on surgical approach, facial nerve outcomes, and the need for improved pre-operative imaging and intra-operative monitoring are discussed. A review of the current literature on nervus intermedius tumour is provided.

Voriconazole is a broad-spectrum azole exhibiting strong anti-Aspergillus activity and good long-term tolerance. However, the evidence for voriconazole efficacy against refractory Aspergillus otomycosis is weak.

We reviewed the medical records of patients with Aspergillus otomycosis treated with voriconazole from January 2008 to June 2012 in a Taiwanese regional hospital. Demographic data and information regarding underlying diseases, clinical features, treatment and outcome were assessed.

In total, 14 cases of Aspergillus otomycosis were treated with voriconazole, including 5 patients with Aspergillus invasive otitis externa. All patients had failed to respond to local treatment, antibiotics or topical agents. One case was lost to follow up. The symptoms of two patients recurred after voriconazole treatment: one patient received a second 12-week course of voriconazole and was cured; and symptoms of the other patient recurred after a second 12-week course of voriconazole, leading to surgical debridement. The remaining 11 patients were cured by voriconazole treatment without extensive surgical debridement.

This study demonstrates that voriconazole can be a very effective and convenient therapeutic option for the management of refractory Aspergillus otomycosis.

Coincident thyroid and head and neck squamous cell carcinomas are rare. This paper presents a case of synchronous laryngeal squamous cell carcinoma, follicular thyroid carcinoma and micropapillary thyroid carcinoma.

A PubMed search was performed for articles describing synchronous thyroid and head and neck squamous cell carcinomas, using the search terms ‘thyroid cancer’, ‘cancer of the head and neck’, ‘synchronous’ and ‘synchronous neoplasm’.

The literature suggests that the head and neck squamous cell carcinoma stage is a better predictor of outcome than the extent of surgical treatment of the thyroid gland in synchronous malignancies.

The decision regarding surgical treatment of the thyroid in synchronous thyroid and head and neck squamous cell carcinomas should take several factors into account. The head and neck squamous cell carcinoma stage is the strongest predictor of outcome, although patient-related factors and the location of malignant thyroid tissue may also affect management.

The larynx is an intricate structure serving three important functions in humans: it protects the lower respiratory airway, facilitates respiration and helps produce sound through a key role in phonation.

We report the first published finding of congenital duplication of the larynx in a patient with previously cleared squamous cell carcinoma of the neck and a new diagnosis of squamous cell carcinoma of the lung.

We describe the incidental finding of duplication of the larynx in a 62-year-old man with previously completely cleared squamous cell carcinoma of the neck, who presented with worsening dyspnoea. We also provide a brief overview of other published cases in which duplication of the vocal folds and epiglottis has been reported.

Our patient experienced no symptoms related to this incidental finding of congenital duplication of the larynx.

The first case of congenital duplication of the larynx is currently of academic interest only; however, the possible association with squamous cell carcinoma is postulated to raise awareness in clinicians who may observe further cases in the future.

This paper reports a rare case of a human immunodeficiency virus infected man with gummatous syphilis of the face.

A 39-year-old man presented with an ulcer of the face which had been slowly progressive over the previous 6 years. Examination showed an ulcerative lesion of the midface involving the cheeks, and completely destroying the nose, the upper lip and part of the lower lip. The teeth and gums were exposed. The ulcer had a moist, purulent base with rolled edges. The patient had human immunodeficiency virus, with a cluster of differentiation 4 count of 641 cells per µl. The rapid plasma reagin test titre was 1:1024 and the Treponema pallidum haemagglutination assay result was positive. Biopsy showed non-necrotising granulomata with a negative Warthin–Starry silver stain. There was a dramatic response to treatment with penicillin.

This case study is a reminder that syphilis needs to be considered in the differential diagnosis of unusual presentations involving skin and bone.

There are only very few reports of cervical toxoplasma lymphadenitis being diagnosed exclusively via fine-needle aspiration cytology (with serology).

We describe a case of toxoplasma lymphadenitis that was successfully diagnosed by fine-needle aspiration cytology. The case involved a male patient who was immunocompromised as a result of recurrent acute myelogenous leukaemia with cervical lymphadenopathy. The biopsy showed typical features of a well-defined pseudocyst containing Toxoplasma gondii tachyzoites.

Toxoplasma lymphadenitis is a common cause of lymph node enlargement. Fine-needle aspiration cytology is a useful method for diagnosing and differentiating toxoplasma lymphadenitis from more serious causes of lymphadenopathy, such as metastatic lymphadenopathy or lymphoma.

We report a case of a patient with symptomatic primary hyperparathyroidism who was found, through a thorough radiological investigation, to also have papillary and medullary thyroid carcinomas.

A 59-year-old female was diagnosed with primary hyperparathyroidism. A further radiological investigation found suspicious areas within both thyroid lobes that were later diagnosed as foci of papillary and medullary thyroid carcinomas. Appropriate treatment was commenced. Reports of similar occurrences of synchronous thyroid and parathyroid pathologies are discussed.

To our knowledge, this is the first reported case of two synchronous thyroid cancers occurring in the context of primary hyperparathyroidism. We strongly recommend a thorough radiological investigation of all patients with primary hyperparathyroidism to prevent missing concurrent thyroid cancers.