One hundred years ago, millions of British and Allied troops were fighting in the trenches of the Great War. With a tenth of soldiers losing their lives, hearing loss seemed a low priority; however, vast numbers of troops sustained significant hearing loss.

A review was conducted of literature published between 1914 and 1925.

Soldiers were exposed to up to 185 dB of sustained noise from new, high-energy weapons, which caused ‘labyrinthine concussion’. Traumatic injuries, non-organic hearing loss and malingering were also common. One source estimated that 2.4 per cent of the army was disabled by hearing loss. However, many British doctors viewed this ‘soldier's deafness’ as a temporary affliction, resulting in soldiers being labelled as malingerers or ‘hysterical’.

Today, one can recognise that a scant evidence base and misconceptions influenced the mismanagement of hearing loss by otolaryngologists in World War I. However, noise-induced hearing loss is still very much a feature of armed conflict.

Mules and other equine species have been used in warfare for thousands of years to transport goods and supplies. Mules are known for ‘braying’, which is disadvantageous in warfare operations. This article explores the fascinating development of surgical techniques to stop military mules from braying, with particular emphasis on the key role played by the otolaryngologist Arthur James Moffett in devoicing the mules of the second Chindit expedition of World War II.

The PubMed database (1900–2017) and Google search engine were used to identify articles related to devoicing mules in the medical and veterinary literature, along with information and images on the Chindit expedition.

This paper reviews the surgical techniques aimed at treating braying in mules, ranging from ventriculectomy and arytenoidectomy to Moffett's approach of vocal cordectomy.

Moffett's technique of vocal cordectomy provided a quick, reproducible and safe solution for devoicing mules. It proved to be advantageous on the battlefield and demonstrated his achievements outside the field of medicine.

A variety of paediatric tracheostomy tubes are available. This article reviews the tubes in current use at Great Ormond Street Hospital for Children and Evelina London Children's Hospital.

This paper outlines our current preferences, and the particular indications for different tracheostomy tubes, speaking valves and other attachments.

Our preferred types of tubes have undergone significant design changes. This paper also reports further experience with certain tubes that may be useful in particular circumstances. An updated sizing chart is included for reference purposes.

The choice of a paediatric tracheostomy tube remains largely determined by individual clinical requirements. Although we still favour a small range of tubes for use in the majority of our patients, there are circumstances in which other varieties are indicated.

To establish the prevalence of hypocalcaemia following laryngectomy and demonstrate that total thyroidectomy is a risk factor.

A retrospective cohort study was conducted that included all patients who underwent total laryngectomy from 1st January 2006 to 1st August 2017. Exclusion criteria were: pre-operative calcium derangement, previous thyroid or parathyroid surgery, concurrent glossectomy, pharyngectomy, or oesophagectomy.

Ninety patients were included. Sixteen patients had early hypocalcaemia (18 per cent), seven had protracted hypocalcaemia (8 per cent) and six had permanent hypocalcaemia (10 per cent). Exact logistic regression values for hypocalcaemia following total thyroidectomy compared to other patients were: early hypocalcaemia, odds ratio = 15.5 (95 per cent confidence interval = 2.2–181.9; model p = 0.002); protracted hypocalcaemia, odds ratio = 13.3 (95 per cent confidence interval = 1.5–117.1; model p = 0.01); and permanent hypocalcaemia, odds ratio = 22.7 (95 per cent confidence interval = 1.9–376.5; model p = 0.005).

This is the largest study to investigate the prevalence of hypocalcaemia following laryngectomy and the first to include follow up of longer than three months. Total thyroidectomy significantly increased the risk of hypocalcaemia at all time frames and independent of other variables.

To evaluate the nasal functions of patients with unilateral chronic otitis media using rhinomanometry, comparing chronic otitis media sides with healthy sides, chronic otitis media patients with cholesteatoma and without cholesteatoma, and patients with healthy individuals.

This prospective study included 102 patients with unilateral chronic otitis media (48 with and 54 without cholesteatoma). The control group comprised 40 individuals without any ear or nasal pathologies. All patients underwent active anterior rhinomanometry to measure nasal airway resistance and a saccharin test to measure mucociliary transport times.

There were no significant differences in nasal airway resistance and mucociliary transport time between the chronic otitis media sides and unaffected sides in the 102 patients (p = 0.72 and p = 0.28, respectively), between the non-suppurative chronic otitis media patients (without cholesteatoma) and chronic otitis media with cholesteatoma patients (p > 0.05), or between the study and control groups (p > 0.05).

The present study, with a larger sample size compared to previously published literature, supports the conclusion that unilateral nasal obstruction is unlikely to lead to chronic otitis media on the same side. The results also suggest that nasal functions do not contribute to the development of cholesteatoma.

This study aimed to present the clinical features and surgical outcomes of juvenile nasopharyngeal angiofibroma patients who were surgically treated.

The medical records of 48 male patients histologically confirmed as having juvenile nasopharyngeal angiofibroma, who underwent transnasal endoscopic surgery between 2005 and 2016, were retrospectively reviewed.

The overall recurrence rate was 20.8 per cent; however, the recurrence rate differed significantly between patients diagnosed aged less than 14 years (34.7 per cent) and more than 14 years (8 per cent) (p < 0.05). Advanced-stage tumours (Radkowski stage of IIC or more, and Önerci stage of III or more) were more aggressive than earlier stage tumours (p < 0.05 and p < 0.01, respectively). Pre-operative embolisation significantly prolonged mean hospitalisation duration, but had no effect on intra-operative blood loss in patients with advanced-stage tumours (p < 0.001 and p = 0.09, respectively).

The findings show that transnasal endoscopic surgery could be considered the treatment of choice for juvenile nasopharyngeal angiofibroma. Patients diagnosed when aged less than 14 years and those with advanced-stage tumours are at risk of recurrence, and should be monitored with extreme care.

To assess, using standardised tools, the quality and readability of online tinnitus information that patients are likely to access.

A standardised review was conducted of websites relating to tinnitus and its management. Each website was scored using the DISCERN instrument and the Flesch Reading Ease scale.

Twenty-seven unique websites were evaluated. The mean DISCERN score of the websites was 34.5 out of 80 (standard deviation = 11.2). This would be considered ‘fair’ in quality. Variability in DISCERN score between websites was high (range, 15–57: ‘poor’ to ‘very good’). Website readability was poor, with a mean Flesch Reading Ease score of 52.6 (standard deviation = 7.7); this would be considered ‘difficult’ to read.

In general, the quality of tinnitus websites is fair and the readability is poor, with substantial variability in quality between websites. The Action on Hearing Loss and the British Tinnitus Association websites were identified as providing the highest quality information.

Perforations of the tympanic membrane are treated with various surgical techniques and materials. This study aimed to determine the efficacy of platelet-rich plasma during underlay myringoplasty.

The study included 40 patients. Autologous platelet-rich plasma was applied in-between temporalis fascia graft and tympanic membrane remnant during underlay myringoplasty in group 1 (n = 20). The outcome was evaluated after three months and compared with group 2 (n = 20), a control group that underwent routine underlay tympanoplasty.

After three months’ follow up, graft uptake was 95 per cent in group 1 and 85 per cent in group 2 (p < 0.03). Mean hearing threshold gain was 18.62 dB in group 1 and 13.15 dB in group 2. This difference was statistically significant (p < 0.01).

Platelet-rich plasma, with its ease of preparation technique, availability, low cost, autologous nature and good graft uptake rate, justifies its use in tympanoplasty type I procedures.

To evaluate the plasma levels of endothelial cell-specific molecule-1 (ESM-1) and pentraxin-3 (PTX-3) in patients with idiopathic sudden sensorineural hearing loss, and to compare the pre- and post-treatment levels in patients responsive and non-responsive to therapy.

The study included 108 subjects: 51 with idiopathic sudden sensorineural hearing loss and 57 controls. For ESM-1 and PTX-3 analyses, blood samples were collected before and three months after treatment initiation in the idiopathic sudden sensorineural hearing loss group and once for the control group. Treatment response was evaluated three months after therapy initiation with pure tone audiometry, and the patients were divided into two groups: responsive and non-responsive to treatment.

Serum ESM-1 levels were significantly higher in the idiopathic sudden sensorineural hearing loss group than the control group, whereas the difference was not significant for PTX-3. In the responsive and non-responsive groups, ESM-1 and PTX-3 levels were not statistically different before and after treatment.

To our knowledge, this is the first study investigating plasma ESM-1 and PTX-3 levels in idiopathic sudden sensorineural hearing loss. Increased plasma ESM-1 levels may confirm endothelial dysfunction involvement in idiopathic sudden sensorineural hearing loss pathogenesis, which could be associated with vascular impairment.

To identify the intracochlear electrode position in cochlear implant recipients and determine the correlation to speech perception for two peri-modiolar electrode arrays.

Post-operative cone-beam computed tomography images of 92 adult recipients of the ‘CI512’ electrode and 18 adult recipients of the ‘CI532’ electrode were analysed. Phonemes scores were recorded pre-implantation, and at 3 and 12 months post-implantation.

All CI532 electrodes were wholly within scala tympani. Of the 79 CI512 electrodes intended to be in scala tympani, 58 (73 per cent) were in scala tympani, 14 (17 per cent) were translocated and 7 (9 per cent) were wholly in scala vestibuli. Thirteen CI512 electrodes were deliberately inserted into scala vestibuli. Speech perception scores for post-lingual recipients were higher in the scala tympani group (69.1 per cent) compared with the scala vestibuli (54.2 per cent) and translocation (50 per cent) groups (p < 0.05). Electrode location outside of scala tympani independently resulted in a 10.5 per cent decrease in phoneme scores.

Cone-beam computed tomography was valuable for demonstrating electrode position. The rate of scala tympani insertion was higher in CI532 than in CI512 electrodes. Scala vestibuli insertion and translocation were associated with poorer speech perception outcomes.

Anteriorly located tympanic membrane perforations can negatively affect surgical success rates. This study aimed to present, using our case series results, endoscopic triple-C (composite chondroperichondrial clip) tympanoplasty as an alternative method in the repair of tympanic membrane anterior quadrant perforations.

This study included patients with a perforation sized greater than 3 mm, who had an anterior quadrant dominant perforation where the anterior portion could not be seen during microscopic examination; all underwent endoscopic triple-C tympanoplasty.

Operating time was 30–79 minutes (mean, 46.6 minutes). The post-operative graft success rate at six months was 92 per cent (23 out of 25). Mean post-operative follow-up duration was 21.5 ± 7.3 months (range, 11–40 months), and no intratympanic cholesteatoma was observed.

Endoscopic triple-C tympanoplasty is a comfortable, minimally invasive alternative method to repair anterior tympanic membrane perforations. The graft success rate and the degree of recovery from hearing loss were in accordance with the literature. However, more reliable results may be obtained in a larger series with longer follow-up times.

To determine: (1) the incidence of incidental ‘mastoiditis’ reported on magnetic resonance imaging scans performed in patients with asymmetrical sensorineural hearing loss and/or unilateral tinnitus; (2) how many of those patients have actual otological pathology and/or require treatment; and (3) the financial implications of such a reporting practice.

Retrospective case series.

Between October 2015 and November 2016, 500 patients underwent magnetic resonance imaging of the internal auditory meatus to rule out cerebellopontine angle lesions. There was an incidental finding of increased mastoid signalling in 5.8 per cent (n = 29), of which 20.7 per cent (6 of 29) were reported as bilateral cases. The diagnosis of ‘mastoiditis’ was found in 39.7 per cent (29 of 73). None of these patients had any pathology identified clinically. Other significant pathology was identified in a further 8.8 per cent (n = 44).

The diagnosis of mastoiditis is primarily clinical. An incidental finding of high signalling in the mastoid region on magnetic resonance imaging is highly unlikely to represent actual clinical disease. In patients who are scanned for other reasons and who do not complain of otological symptoms, such findings are unlikely to require otolaryngology input.

Factors specific to sub-Saharan Africa could have an impact on tympanic membrane perforation characteristics. Obtaining precise information on these characteristics and determinants of hearing loss severity would enable better management.

To determine the relationship between characteristics of tympanic membrane perforation and subsequent hearing impairment.

A cross-sectional study of consenting patients presenting with tympanic membrane perforation was conducted. They were examined using otoendoscopy with a digital camera to obtain precise measurements, followed by pure tone audiometry.

Eighty-six cases of tympanic membrane perforation were included. Mean tympanic membrane perforation proportion was 34.1 ± 18.4 per cent. Medium-sized tympanic membrane perforations were predominant (47.7 per cent). Median tympanic membrane perforation duration was 20 years. Tympanic membrane perforation size was found to be a predictor of hearing loss severity (odds ratio = 2.5, 95 per cent confidence interval = 1.02–6.13, p = 0.04).

Tympanic membrane perforation size was a predictor of hearing loss severity in our setting. Site, duration and aetiology seem to have no impact on hearing loss severity.

Eosinophils are the principal effector cells involved in the pathogenesis of allergic rhinitis. Cell numbers increase in non-allergic rhinitis patients with eosinophilia, aspirin hypersensitivity and nasal polyposis, as well as in allergic rhinitis patients. Exfoliative nasal cytology can be used in the differential diagnosis of allergic rhinitis.

To evaluate nasal eosinophilia in nasal smears of patients with mild, persistent and intermittent allergic rhinitis.

The study comprised 60 patients with allergic rhinitis and 20 healthy volunteers. The patients were divided into intermittent and persistent allergic rhinitis groups. Nasal smear status, eosinophil numbers and Total Nasal Symptom Scores were compared.

Nasal smear results were pathological in 40 of 60 allergic rhinitis patients, which was significantly higher than the rate in controls. The mean nasal eosinophilia score was significantly higher in the intermittent allergic rhinitis than in the persistent allergic rhinitis group (p = 0.029). There was a positive correlation between nasal eosinophilia score and Total Nasal Symptom Score (r = 0.652; p < 0.05) in persistent allergic rhinitis and intermittent allergic rhinitis patients.

The nasal smear test is inexpensive, objective and simple to perform, and should be part of the diagnostic investigation.

Middle-third helical rim defects may arise from trauma or oncological resection, and pose a challenging reconstructive problem. Reconstructing defects larger than 2 cm using traditional methods commits patients to the inconvenience of staged procedures.

This paper describes a single-stage helical rim reconstruction technique using a post-auricular bipedicled flap and ipsilateral conchal cartilage graft for delayed middle-third helical rim reconstruction.

Two examples of this technique used in post-trauma and oncological reconstruction cases are presented, with pre- and post-operative photographs provided for demonstration.

Contralateral graft harvest and staged operations for helical rim reconstruction are associated with donor site morbidity and the inconvenience of multiple operations to achieve the desired reconstructive outcome. Our single-stage helical rim reconstruction technique was well tolerated by patients, and showed satisfactory aesthetic results in terms of size and symmetry.

Parapharyngeal space biopsy is an important investigation in the management of parapharyngeal space tumours. These tumours are relatively rare and the surgeon is often faced with a wide range of differential diagnoses. There are several ways to access the parapharyngeal space, with varying degrees of associated morbidity.

This paper describes a seldom used, but a simple and safe, image-guided endoscopic approach to parapharyngeal space biopsy that enables tissue to be obtained transnasally. The procedure is conducted under general anaesthesia using computed tomography image guidance via the LandmarX system, with transnasal access to the parapharyngeal space achieved using a sampling needle.

This procedure is relatively simple, safe and reproducible. It is a less invasive approach to parapharyngeal space biopsy, and one which has been successfully used by the senior author for years without any significant morbidity.

Transnasal image-guided endoscopic aspiration or biopsy of the parapharyngeal space is a novel technique that has not been previously described.

There is currently no general consensus on patulous Eustachian tube management. Injection of autologous fat, cartilage or hydroxylapatite has been described for Eustachian tube occlusion, with promising results. However, complete resolution of symptoms is not achieved in all cases. This could be connected to the amount of material injected into the surroundings of the Eustachian tube, as this greatly differs among existing studies. Identifying the appropriate volume of injected material could be challenging because anatomical conditions vary among patients, and there is always a risk of chronic Eustachian tube obstruction and its related complications when too much long-standing material is injected.

A case is presented wherein saline was injected under local anaesthesia to determine the volume required and to predict the success of patulous Eustachian tube augmentation with long-standing material.

This approach could allow more personalised treatment and help identify patients likely to benefit from the procedure.

This case report illustrates an unusual case of a dural arteriovenous fistula and an associated encephalocele presenting as otitis media with effusion.

A 53-year-old man presented with right-sided hearing loss and aural fullness of 2 years’ duration. Examination revealed ipsilateral post-auricular pulsatile tenderness. Computed tomography showed transcalvarial channels suggestive of dural arteriovenous fistula. Further magnetic resonance imaging demonstrated the presence of a temporal encephalocele herniating through the tegmen tympani defect, as well as the abnormal vascularity. Angiography confirmed a Cognard type I dural arteriovenous fistula, which is being managed conservatively. Surgical repair of the encephalocele was recommended but declined by the patient.

Dural arteriovenous fistula is an uncommon intracranial vascular malformation rarely seen by otolaryngologists, with pulsatile tinnitus being the usual presentation. To our knowledge, this is the first reported case of dural arteriovenous fistula presenting with conductive hearing loss and otalgia.

The benefit of mandibular advancement devices in patients with sleep-disordered breathing and as a potential option for obstructive sleep apnoea syndrome is well recognised. Their use in the setting of epilepsy or other seizure disorders is typically contraindicated.

A 48-year-old patient with a history of poorly controlled epilepsy and obstructive sleep apnoea syndrome was referred for ENT review for possible tracheostomy. The patient was wheelchair-bound with 24-hour continuous positive airway pressure, but sleep studies demonstrated persistent, severe episodes of apnoea and notable sleep disturbance. Sleep nasendoscopy demonstrated marked improvement on capnography with the laryngeal mask airway in situ, and this was maintained with mandibular advancement using jaw thrust following removal of the laryngeal mask airway. A mandibular advancement device was subsequently trialled; this had no subjective benefit for the patient, but the seizures resolved and control of apnoea was achieved with the combination of a mandibular advancement device and continuous positive airway pressure.

This paper highlights a novel application of mandibular advancement devices, used in combination with continuous positive airway pressure, which resulted in complete resolution of sleep deprivation and apnoea-induced epileptic events.