Atlanto-axial rotatory fixation is a persistent deformity of the C1–2 vertebral relationship caused by subluxation of the articular surfaces, and can occur after positioning for ENT procedures where the head is rotated – for example to access the ear or posterior triangle of the neck. If promptly recognised, it can usually be managed successfully with conservative methods, without long-lasting sequelae, but delayed or inappropriate management may lead to permanent neck deformity, neurological problems and pain.

Case review.

Two children with atlanto-axial rotatory fixation following ENT surgery; one child was referred early and managed successfully, and one had delayed referral resulting in permanent severe positional deformity.

Atlanto-axial rotatory fixation is easily missed; there are significant clinical and medicolegal implications if it is not promptly recognised. A suggested management algorithm is presented.

The advent of supraglottoplasty clearly has transformed the surgical management of severe laryngomalacia. The condition, however, generally runs a milder course, with spontaneous resolution the norm.

To identify gaps in the knowledge and identify topics for future study.

Systematic review of the literature.

The literature suggests that there is a range of abnormalities leading to the typical collapsing upper airway, and that neurological disease, other airway abnormalities, syndromes and gastroesophageal reflux all contribute to disease severity and influence outcomes. The procedures involved in supraglottoplasty are rarely specified, the indications for surgery are vaguely defined and the role of medical therapy is unclear.

Every review article or survey of opinion suggests that there is still a marked variation in individual practice and a lack of consensus.

To investigate the effect of microRNA let-7a on OPN expression in a mouse model of allergic rhinitis.

Thirty-two mature female C57BL/6 mice were randomly divided into four groups, with eight mice in each group: microRNA let-7a, microRNA control, OVA and phosphate-buffered saline groups. The microRNA let-7a, microRNA control and OVA groups were sensitised with OVA to establish a mouse model of allergic rhinitis. Nose-scratching events were counted. Nasal mucosa was used to evaluate histological changes of goblet cell hyperplasia. Interleukins 5 and 13 were detected. Interferon-γ levels in the nasal lavage fluid were assayed with enzyme-linked immunosorbent assay. OPN expression was estimated with polymerase chain reaction.

Compared with microRNA control mice, microRNA let-7a treated mice had a significantly increased number of nose-scratching events, nasal mucosal eosinophilia and goblet cell hyperplasia (p < 0.05), and significantly higher interleukins 5 and 13 in nasal mucosa (p < 0.05), but there was no significant difference in interferon-γ (p > 0.05). In addition, microRNA let-7a treated mice had significantly enhanced OPN expression in nasal mucosa (p < 0.05).

MicroRNA let-7a can promote allergic rhinitis development partly by regulating OPN expression.

Patients with advanced otosclerosis can present with hearing thresholds eligible for cochlear implantation. This study sought to address whether stapes surgery in this patient group provides a clinically significant audiological benefit.

To assess pre- and post-operative hearing outcomes of patients with advanced otosclerosis, and to determine what proportion of these patients required further surgery including cochlear implantation.

Between 2002 and 2015, 252 patients underwent primary stapes surgery at our institution. Twenty-eight ears in 25 patients were deemed to have advanced otosclerosis, as defined by pure audiometry thresholds over 80 dB. The patients’ records were analysed to determine audiological improvement following stapes surgery, and assess whether any further surgery was required.

The audiological outcome for most patients who underwent primary stapes surgery was good. A minority of patients (7 per cent) required revision surgery. Patients who underwent cochlear implantation after stapes surgery (10 per cent) also demonstrated a good audiological outcome.

Stapes surgery is a suitable treatment option for patients with advanced otosclerosis, and should be considered mandatory, before offering cochlear implantation, for those with a demonstrable conductive component to their hearing loss. A small group of patients get little benefit from surgery and subsequently a cochlear implant should be considered.

This study aimed to screen young adults for sleep-disordered breathing, and compare those with high and low risk for sleep-disordered breathing.

A survey based on the Berlin questionnaire was completed by 330 university students, and the results were used to divide them into sleep-disordered breathing positive and sleep-disordered breathing negative groups. A representative group was selected from each cohort (positive group, n = 16; negative group, n = 21), and assessed with sleep study, ENT examination, the Nose Obstruction Symptom Evaluation scale, and the Epworth Sleepiness Scale.

Sleep-disordered breathing prevalence was 11.2 per cent in the questionnaire and 24 per cent according to the sleep study. The sleep-disordered breathing positive and negative groups significantly differed in terms of coexisting sleep-disordered breathing symptoms. There were no significant differences between the positive and negative groups with regard to sleep study parameters (apnoea/hypopnoea index, respiratory disturbance index, oxygen desaturation index, snoring intensity) and the Epworth Sleepiness Scale.

Subjective and objective diagnostic tools revealed that sleep-disordered breathing is a common problem among young adults.

To analyse the relationship of pre-operative body mass index with surgical complications and oncological outcomes in patients undergoing microvascular reconstruction for head and neck squamous cell cancer.

A retrospective review was conducted of 259 patients who underwent microvascular free flap reconstruction after head and neck ablative surgery.

Mean body mass index was 22.48 kg/m2. There were no correlations between body mass index and: flap failure (p = 0.739), flap ischaemia (p = 0.644), pharyngocutaneous fistula (p = 0.141) or wound infection (p = 0.224). The five-year disease-specific survival rate was 63 per cent. On univariate analysis, the five-year disease-specific survival rate was significantly correlated with pre-operative body mass index, based on Kaplan–Meier survival curves (p = 0.028). The five-year disease-specific survival rates in underweight, normal weight, overweight and obese groups were 47 per cent, 55 per cent, 65 per cent and 80 per cent, respectively.

Pre-operative body mass index was a useful predictor for recurrence and survival in patients who underwent microvascular reconstruction for head and neck squamous cell cancer.

Throat swabs are neither specific nor sensitive for micro-bacteria causing sore throat symptoms; however, current guidelines suggest they are still useful in some cases.

Retrospective and prospective analyses were conducted of throat swabs requested within the months of January 2016 and August 2016, respectively.

The study comprised 247 patients. Fifty-nine (24 per cent) had a positive culture. Forty-six grew group A beta-haemolytic streptococci, with the remainder growing candida (n = 10), coliform (n = 1) and klebsiella (n = 2). There was no significant difference in culture rates between primary or secondary care sources (χ2 = 0.56, p = 0.45). None of the swabs influenced a variation in patient management from local antimicrobial policies. Current practice has an estimated annual financial impact of £3 434 340 on the National Health Service.

Throat swabs do not influence the antimicrobial treatment for patients with sore throats, even under current guidelines, and incur unnecessary cost. Current clinical guidelines could be reviewed to reduce the number of throat swabs being conducted unnecessarily.

To characterise multi-level obstruction in terms of prevalence, obstructive sleep apnoea severity and predictive factors, and to collect epidemiological data on upper airway morphology in obstructive sleep apnoea patients.

Retrospective review of 250 obstructive sleep apnoea patients.

On clinical examination, 171 patients (68.4 per cent) had multi-level obstruction, 49 (19.6 per cent) had single-level obstruction and 30 (12 per cent) showed no obstruction. Within each category of obstructive sleep apnoea severity, multi-level obstruction was more prevalent. Multi-level obstruction was associated with severe obstructive sleep apnoea (more than 30 events per hour) (p = 0.001). Obstructive sleep apnoea severity increased with the number of obstruction sites (correlation coefficient = 0.303, p < 0.001). Multi-level obstruction was more likely in younger (p = 0.042), male (p = 0.045) patients, with high body mass index (more than 30 kg/m2) (p < 0.001). Palatal (p = 0.004), tongue (p = 0.026) and lateral pharyngeal wall obstructions (p = 0.006) were associated with severe obstructive sleep apnoea.

Multi-level obstruction is more prevalent in obstructive sleep apnoea and is associated with increased severity. Obstruction at certain anatomical levels contributes more towards obstructive sleep apnoea severity.

To describe the feasibility and assess the safety of using an ultrasonic bone aspirator in endoscopic ear surgery.

Five temporal bones were dissected via endoscopic ear surgery using a Sonopet ultrasonic bone aspirator. Atticoantrostomy was undertaken. Another four bones were dissected using routine endoscopic equipment and standard bone curettes in a similar manner. Feasibility and safety were assessed in terms of: dissection time, atticoantrostomy adequacy, tympanomeatal flap damage, chorda tympani nerve injury, ossicular injury, ossicular chain disruption, facial nerve exposure and dural injury.

The time taken to perform atticoantrostomy was significantly less with the use of the ultrasonic bone aspirator as compared to conventional bone curettes.

The ultrasonic bone aspirator is a feasible option in endoscopic ear surgery. It enables easy bone removal, with no additional complications and greater efficacy than traditional bone curettes. It should be a part of the armamentarium for transcanal endoscopic ear surgery.

Intranasal steroid sprays are fundamental in the medical management of inflammatory rhinological conditions. Side effects are common, but these may be related to the method of application rather than the medication itself.

A survey was distributed to patients using intranasal steroid sprays at the ENT out-patient clinic at Aberdeen Royal Infirmary over three months. This evaluated the spray technique used, side effects and compliance.

Of 103 patients, 22 patients (21.4 per cent) reported side effects, including nasal irritation and epistaxis. Of the 20 patients with epistaxis, 80 per cent used an ipsilateral hand technique (p = 0.01). Thirty patients demonstrated poor compliance because of lack of symptom improvement or side effects. Seventy-seven per cent of this group used the ipsilateral hand technique.

Patients who used their ipsilateral hand to apply the intranasal steroid spray were more likely to develop epistaxis and have poor compliance than those who used other techniques. Patients who struggle with compliance because of side effects should avoid this method of intranasal steroid application.

Allergic rhinitis is strongly associated with the presence of house dust mites. This study investigated the long-term effects of allergen-specific immunotherapy. Allergen-specific immunotherapy was applied over three years. The study was based on a 10-year follow up of patients with allergic rhinitis.

The study was conducted between 2001 and 2015. Skin prick test results and symptom scores were evaluated before (26 patients) and after 3 years (20 patients) of allergen-specific immunotherapy (using data from a previously published study), and 10 years after allergen-specific immunotherapy had ended (20 of 26 patients).

The symptom scores before allergen-specific immunotherapy were significantly higher than those obtained after 3 years of allergen-specific immunotherapy and 10 years after allergen-specific immunotherapy (p < 0.0175). There were no significant differences between the scores obtained at 3 years and 10 years after allergen-specific immunotherapy (p > 0.0175).

Subcutaneous immunotherapy is an effective treatment for house dust mite induced allergic rhinitis.

The present humanitarian crisis in Ukraine is putting strains on its healthcare system. This study aimed to assess services and training in otolaryngology, audiology and speech therapy in Ukraine and its geographical neighbours.

Survey study of 327 otolaryngologists from 19 countries.

Fifty-six otolaryngologists (17 per cent) from 15 countries responded. Numbers of otolaryngologists varied from 3.6 to 12.3 per 100 000 population (Ukraine = 7.8). Numbers of audiologists varied from 0, in Ukraine, to 2.8 per 100 000, in Slovakia, and numbers of speech therapists varied from 0, in Bulgaria, to 4.0 per 100 000, in Slovenia (Ukraine = 0.1). Ukraine lacks newborn and school hearing screening, good availability of otological drills and microscopes, and a cochlear implant programme.

There is wide variation in otolaryngology services in Central and Eastern Europe. All countries surveyed had more otolaryngologists per capita than the UK, but availability of audiology and speech and language therapy is poor. Further research on otolaryngology health outcomes in the region will guide service improvement.

The provision of healthcare education in developing countries is a complex problem that simulation has the potential to help. This study aimed to evaluate the effectiveness of a low-cost ear surgery simulator, the Ear Trainer.

The Ear Trainer was assessed in two low-resource environments in Cambodia and Uganda. Participants were video-recorded performing four specific middle-ear procedures, and blindly scored using a validated measurement tool. Face validity, construct validity and objective learning were assessed.

The Ear Trainer provides a realistic representation of the ear. Construct validity assessment confirmed that experts performed better than novices. Participants displayed improvement in all tasks except foreign body removal, likely because of a ceiling effect.

This study validates the Ear Trainer as a useful training tool for otological microsurgical skills in developing world settings.

Chronic tinnitus is associated with reduced auditory input, which results in changes in the central auditory system. This study aimed to examine the relationship between tinnitus pitch and parameters of audiometry and distortion product otoacoustic emissions. For audiometry, the parameters represented the edge frequency of hearing loss, the frequency of maximum hearing loss and the frequency range of hearing loss. For distortion product otoacoustic emissions, the parameters were the frequency of lowest distortion product otoacoustic emission amplitudes and the frequency range of reduced distortion product otoacoustic emissions.

Sixty-seven patients (45 males, 22 females) with subjective chronic tinnitus, aged 18 to 73 years, were included.

No correlation was found between tinnitus pitch and parameters of audiometry and distortion product otoacoustic emissions. However, tinnitus pitch fell mostly within the frequency range of hearing loss.

The current study seems to confirm the relationship between tinnitus pitch and the frequency range of hearing loss, thus supporting the homeostatic plasticity model.

Non-traumatic bone fractures in cancer patients are usually pathological fractures due to bone metastases. In head and neck cancer patients, clavicle stress fractures may occur as a result of atrophy of the trapezius muscle after neck dissection in which the accessory nerve becomes structurally or functionally damaged.

A 71-year-old man underwent modified radical neck dissection with accessory nerve preservation and post-operative radiotherapy for submandibular lymph node metastases of tongue cancer. Four weeks after the radiotherapy, a clavicle fracture, with osteomyelitis and abscess formation in the pectoralis major muscle, occurred. Unlike in simple stress fracture, long-term antibiotic administration and drainage surgery were required to suppress the inflammation.

As seen in the present patient, clavicle stress fractures may occur even after neck dissection in which the accessory nerve is preserved, and may be complicated by osteomyelitis and abscess formation owing to risk factors such as radiotherapy, tracheostomy and contiguous infection.