Most patients with hereditary haemorrhagic telangiectasia suffer with frequent episodes of epistaxis. The aim of this case report is to highlight the effect on epistaxis, occurring in hereditary haemorrhagic telangiectasia, when nasal airflow ceases.

We present the interesting case of a patient with hereditary haemorrhagic telangiectasia who experienced cessation of her recurrent, refractory epistaxis through the development of coexisting polyp disease. The patient's enlarged, grade three nasal polyps were behaving as physiological obturators, limiting airflow through her nose. This reduced the intranasal trauma and subsequent frequency of her nosebleeds.

Epistaxis is a debilitating part of hereditary haemorrhagic telangiectasia, and poses a frequent management challenge. Our patient was more tolerant of her grade three nasal polyps than of her recurrent epistaxis. This case highlights the importance of reducing nasal airflow when treating patients with hereditary haemorrhagic telangiectasia.

Dysphonia is common in children, but practice varies considerably regarding what, if any, investigations are performed and how the condition is managed. Although childhood dysphonia is mostly due to non-serious causes such as voice misuse, very serious pathology such as papillomatosis or malignancy needs occasionally to be excluded, and treatable congenital anomalies such as webs and cysts can be missed. Voice clinics and voice therapy services are now well established in most adult health services in the developed world, but equivalent services for children are less common, at least in the UK.

We retrospectively reviewed the records of all children presenting to our large children's hospital with a primary complaint of dysphonia between January 2001 and October 2007, in order to determine their management, investigations and final diagnosis.

We identified 142 children. Case records were found for 137 (97 per cent). Eight-three children were male (61 per cent) and 54 female (39 per cent). Ages ranged from two months to 15 years (median 5.3 years). In 10 children (7 per cent), hoarseness was congenital, presenting as a hoarse, weak cry at birth. In 15 children (11 per cent), onset of hoarseness was related to a specific surgical procedure. The larynx was visualised by mirror alone in 23 children (17 per cent), by awake fibre-optic laryngoscopy in 27 (20 per cent) and by microlaryngoscopy-bronchoscopy under anaesthesia in 42 (31 per cent). Forty children (29 per cent) did not undergo laryngeal visualisation at any time and were diagnosed based on history alone. A further five (4 per cent) were scheduled for direct laryngoscopy but this was not performed due to resolution of symptoms. Voice abuse accounted for 62 (45 per cent) of all diagnoses.

Childhood dysphonia accounts for a large number of referrals. There is considerable variation in how these children are managed. A more structured approach to diagnosis and investigation would be beneficial, perhaps within the setting of a dedicated paediatric voice clinic.

To present the historical development of specific instruments used for mastoidectomy and their resulting implications for this surgery.

Compilation of original written documents, trade catalogues and collections of instruments used in mastoid surgery, with a review of the secondary literature on the subject.

The first surgical opening of the mastoid was performed by Petit in 1736 with a trepanation system. More than one and a half centuries later, in 1873, Schwartze codified the operation using chisels and gouges. At the end of the nineteenth century, Macewen introduced the electrical dental burr for mastoid surgery, but it remained largely unrecognised. At the beginning of the 1950s, the systematic use of the microscope in ear surgery allowed generalised use of the drill and improvement of the suction-irrigation system.

Three instrumental periods are recognisable in the history of mastoidectomy: the trepan period, the chisel and gouge period, and the electrical drill period.

Although most studies on animal ototoxicity employ scanning electron microscopy, all cochlear structures may be identified with light microscopy. This paper describes a simple method of histological assessment of cisplatin-induced ototoxicity in rats, and relates morphological changes to functional changes in hearing detected by distortion product evoked otoacoustic emissions.

Male Wistar rats were injected with 8 mg/kg/day cisplatin, or with an equivalent volume of saline solution, for three consecutive days. They underwent distortion product evoked otoacoustic emission testing at baseline and at 24 or 48 hours after the last administration. At the end of the experiment, the animals were sacrificed and their cochleae were retrieved and prepared for haematoxylin and eosin staining.

A four-point scoring system was used to grade injury to the external ciliated cells, as indicated by the number of cells absent from the basal turn of the cochlear duct. A four-point scoring system was also used to grade stria vascularis injury, as indicated by the degree of shrinkage of the intermediate cells. Scores were significantly higher in groups treated with cisplatin compared with controls. Morphological changes were confirmed by decreased distortion product evoked otoacoustic emission amplitudes in animals treated with cisplatin.

This method is simple to perform with routine histology equipment and is appropriate for the study of acute, cisplatin-induced ototoxicity in rats.

To research the protective effect of melatonin against gentamicin ototoxicity.

Guinea pigs were randomly divided into four groups. The first group received intramuscular gentamicin (120 mg/kg body weight/day) for 17 days. Over the same time period, a second group simultaneously received intramuscular gentamicin (120 mg/kg body weight/day) plus (on the other side) intramuscular melatonin (0.3 ml kg body weight/day). Two groups of controls were treated for 17 days with either intramuscular melatonin or intramuscular saline. After the 17 days, each animal underwent distortion product otoacoustic emission testing (both ears). The guinea pigs were sacrificed by decapitation just after the final injection. Their cochleae were used to produce a tissue section, surface preparation and scanning electron microscope preparation.

Distortion product otoacoustic emission testing indicated gentamicin-induced hearing loss at 3, 4, 6 and 8 kHz in gentamicin-treated animals. Animals receiving melatonin co-therapy had significantly attenuated hearing loss and their cochleae showed lower rates of outer hair cell loss (comparing the same cochlear turns), compared with gentamicin-treated animals (p < 0.01).

These findings confirm the occurrence of outer hair cell loss after gentamicin treatment, and the attenuation of such loss following simultaneous melatonin injection, using the method of morphological evaluation. These results suggest that melatonin protects against gentamicin ototoxicity by interfering with cytotoxic mechanisms.

Optical coherence tomography was used to study the stapes footplate, both in cadaveric temporal bones and during middle-ear surgery.

Optical coherence tomography was conducted on five temporal bone preparations (from two children and three adults) and in eight patients during middle-ear surgery. A specially equipped operating microscope with integrated spectral domain optical coherence tomography apparatus was used for standard middle-ear surgical procedures.

This optical coherence tomography investigation enabled in vivo visualisation and documentation of the annular ligament, the different layers of the footplate and the inner-ear structures, both in non-fixed and fixed stapes footplates. In cases of otosclerosis and tympanosclerosis, an inhomogeneous and irregularly thickened footplate was found, in contrast to the appearance of non-fixed footplates. In both fixed and non-fixed footplates, there was a lack of visualisation of the border between the footplate and the otic capsule.

Investigation of the relatively new technology of optical coherence tomography indicated that this imaging modality may assist the ear surgeon to assess the oval window niche intra-operatively.

To evaluate the effectiveness of hyperbaric oxygen therapy in the management of sudden hearing loss.

Patients with sudden hearing loss were divided into study and control groups. The 36 patients in the study group were treated with hyperbaric oxygen therapy in addition to standard medical therapy, whereas the 21 patients in the control group were treated with only standard medical therapy.

Both groups were treated with standard therapy, comprising prednisolone starting at a dose of 1 mg/kg and reducing over three weeks. Patients in the study group received hyperbaric oxygen therapy in addition to standard drug therapy.

Success rates were 78.95 per cent in the study group and 71.30 per cent in the control group. However, this difference was not statistically significant (p > 0.05).

Considering the cost of hyperbaric oxygen therapy and its inconvenience to patients, this treatment should only be considered in patients suffering sudden hearing loss if there are contraindications to standard medical treatment.

To characterise the spectrum of nasal symptomatology and nasendoscopic abnormalities seen in patients attending an asthma clinic, and to relate these symptoms to the likelihood of finding nasendoscopic abnormalities which merit treatment.

Forty-three patients attending a problem asthma clinic were enrolled in an observational study. Cardinal nasal symptoms – obstruction, congestion, hyposmia, rhinorrhoea, sneezing, epistaxis or other symptoms – were graded as none (zero), mild (one), moderate (two) or severe (three), giving a maximum nasal symptom score of 21. Asthma symptoms and lung function were measured. Nasendoscopy was then performed.

Obstruction was the most common cardinal nasal symptom (seen in 15 patients), the median nasal symptom score was 5.3 (range zero to 14) and only three patients had no nasal symptoms. There was no correlation between nasal symptom score and severity of asthma symptoms or forced expiratory volume in one second. Twenty-two patients had a normal appearance on ENT examination (median nasal symptom score four). The nasendoscopic abnormalities seen comprised polyps (n = 8; median nasal symptom score five), deviated nasal septum (n = 7; median nasal symptom score four), oedematous mucosa (n = 4; median nasal symptom score seven) and other abnormalities (n = 2). Individual nasal symptoms were poor predictors of individual nasal pathologies, with hyposmia the best individual predictor of any abnormality (positive predictive value 80 per cent). The presence of a combination of symptoms increased the likelihood of any nasendoscopic abnormality, with obstruction, rhinorrhoea and hyposmia together having a positive predictive value of 100 per cent.

Nasal symptoms are much more frequent than structural abnormalities in patients attending a problem asthma clinic. The threshold for ENT referral should be lower when the patient complains of a symptom complex including hyposmia. Furthermore, concurrent hyposmia, obstruction and rhinorrhoea should be seen as an indication for ENT referral.

Functional endoscopic sinus surgery is the mainstay of surgical treatment for chronic sinusitis. Day-case surgery has the advantage over in-patient surgery of being cost-effective and resource sparing. The objectives of this study were to assess our results for day-case functional endoscopic sinus surgery.

This was a retrospective case note review of day-case functional endoscopic sinus surgery procedures performed at Leeds General Infirmary from February 2004 to February 2007. We recorded patients' demographic data, operative details, post-operative course and follow-up results.

A total of 105 day-case functional endoscopic sinus surgery procedures were included in the study. Patients' ages ranged from 16 to 93 years; 44 (41.9 per cent) were female and 61 (58.1 per cent) were male. Of these patients, 39 (37.1 per cent) had chronic sinusitis and the rest (66; 62.8 per cent) had nasal polyposis and sinusitis. Sixty-one patients (58.1 per cent) underwent surgery on the morning operating list, while the rest (44; 41.9 per cent) underwent surgery in the afternoon. Of the 105 patients, 24 (22.8 per cent) had undergone previous nasal surgery. The majority of patients (90/105; 85.7 per cent) were discharged on the same day as surgery. The only complication recorded in this study was bleeding, noted in seven patients (6.7 per cent). At the follow-up appointment, 90/105 (85.7 per cent) patients were satisfied with their post-operative results.

Day-case endoscopic sinus surgery can be performed safely as a day-case procedure. The most important factors for a successful outcome are correct patient selection, in terms of general health and social circumstances, and a dedicated day-case team.

After treatment of epistaxis, patients are routinely supplied with an intranasal bactericidal cream containing neomycin. Neomycin cream is effective in preventing recurrent paediatric epistaxis. This study aimed to assess whether there is an increased rate of nasal bacterial infections in adult epistaxis patients.

Between October 2004 and April 2005, nasal swabs were taken from adult patients presenting with epistaxis, and from a control group comprising elective ENT patients.

There were 23 controls and 26 epistaxis patients. Staphylococcus aureus was grown in 21 per cent and 23 per cent, respectively. There was no significant difference in bacterial carriage rates between the epistaxis and control groups.

The epistaxis and control groups demonstrated the same bacterial species and the same proportion of bacterial carriage. Although the majority of bacterial species encountered were sensitive to neomycin, a significant proportion was not. These results do not support the routine use of neomycin in the prevention of recurrent adult epistaxis.

To evaluate if phenylephrine–lignocaine mixture (Cophenylcaine) nasal spray performs better than xylometazoline (Otrivine) spray for the purposes of out-patient rigid nasendoscopy preparation.

Prospective, double-blind, randomised trial comparing visual analogue scores for out-patients receiving either phenylephrine–lignocaine mixture or xylometazoline, prior to undergoing rigid nasendoscopy as part of their assessment.

Seventy-three patients requiring rigid nasendoscopy as part of their assessment were recruited to the study from Raigmore Hospital's out-patient clinic. These patients were randomised to receive a nasal spray comprising either phenylephrine–lignocaine mixture or xylometazoline, 10 minutes prior to rigid nasendoscopy. Double-blinding was adopted. After the procedure, the patient and the doctor independently completed separate visual analogue score-based questionnaires regarding the pain of the procedure and the ease of the examination, respectively.

Analysis of the data using standardised statistical methods demonstrated that the phenylephrine–lignocaine mixture did not perform better than xylometazoline, to any statistically significant extent.

Phenylephrine–lignocaine mixture is considerably more expensive and has potentially more side effects than xylometazoline. These study findings suggest that it is difficult to justify the use of phenylephrine–lignocaine mixture over xylometazoline, for nasal preparation prior to rigid nasendoscopy.

Fungal rhinosinusitis has gained much attention in recent years. To our knowledge, no previous studies have addressed the role of fungus in primary atrophic rhinitis.

Prospective case study.

All cases of primary atrophic rhinitis presenting to the out-patient department at El-Sahel Teaching Hospital over a five-month period were included in the study. Crusts and purulent secretions removed from patients' nasal cavities underwent microbiological analysis at the Medical Microbiology and Immunology department of the Cairo University Faculty of Medicine. Special emphasis was placed on fungal isolation.

Fourteen consecutive cases of primary atrophic rhinitis were studied in the five-month period starting 26 November 2007. Patients comprised eight females and six males, with an age range of 12 to 65 years (mean 37 years). Microscopy of the crusts and purulent secretions showed pus cells in most of the samples. Klebsiella species were isolated from nine patients (65 per cent), and other bacterial species were isolated in most of the remainder. Fungal elements, most commonly aspergillus species, were isolated in 13 patients (93 per cent).

It is proposed that the initial trigger for primary atrophic rhinitis is a virulent bacterial infection of the nasal lining, which leads to damage of the ciliated epithelium. This initiates the cascade of events leading to inflammation of the mucosa and submucosa, with secondary pyogenic osteomyelitis of the turbinate bone. The persistence of purulent secretion, within the setting of impaired mucociliary clearance, leads to saprophytic fungal colonisation which contributes greatly to the clinical picture.

To provide an up to date review of the literature on aneurysmal bone cysts, including their diagnosis, pathology, pathophysiology, radiology and management.

Retrospective review of six cases over a 15-year period.

Six patients (age range, eight months to 17 years; mean, 9.6 years) presented with an aneurysmal bone cyst in the mandible (n = 3), maxilla (n = 2) or occipital soft tissue (n = 1). Each patient underwent primary excision, with one subsequent recurrence.

Aneurysmal bone cysts are benign but locally destructive entities which may occasionally present to otolaryngologists, since they can involve the head and neck region, in particular the mandible.

To compare three methods of haemostasis used for ‘cold steel’ tonsillectomy, in terms of pain scores and morbidity.

Prospective, randomised, single-blinded, controlled clinical study. Three haemostasis methods were compared: compression of the tonsillar fossae with gauze packs; bipolar diathermy; and local anaesthesia then pack compression. The outcome measures were pain scores (derived from a visual analogue scale), peri-operative bleeding, and post-operative episodes of blood-stained saliva, consultation rate, tonsillar bed healing and days before return to regular diet. One hundred and five patients were included.

Peri-operative bleeding was significantly reduced in the local anaesthesia group compared with the other two groups. Delayed post-operative tonsillar bed healing was noted in the diathermy group. No other significant differences were found between the three haemostasis groups, for any other outcome measures. The presence of blood-stained saliva was associated with higher pain scores.

Diathermy and compression were associated with similar post-tonsillectomy morbidity.

The study aimed to delineate the relationship between 18F-fluorodeoxyglucose uptake and histological findings in nasopharyngeal carcinoma.

We conducted a retrospective review of 88 patients referred to our positron emission tomography department with newly diagnosed, biopsy-proved nasopharyngeal carcinoma. Hospital records were reviewed for demographic and clinical data, including age, gender, body weight, histological analysis and clinical tumour stage.

Nineteen out of the 88 patients (22 per cent) had nasopharyngeal carcinoma of World Health Organization type I, 39 (44 per cent) had type II and 30 (34 per cent) had type III. The mean standardised uptake value for the primary tumour was 9.4 ± 5.0, ranging from 2.2 to 27.1. The mean standardised uptake values were 8.0 ± 3.9 for type I tumours, 9.7 ± 4.4 for type II tumours and 10.1 ± 6.3 for type III tumours (p = 0.451).

Our study found that type III nasopharyngeal carcinoma exhibited a higher 18F-fluorodeoxyglucose uptake than either type II or type I nasopharyngeal carcinoma. However, this difference was not statistically significant.

To investigate whether the possible pressure produced by a haematoma in the neck would be sufficient to directly compress the trachea to the point of airway obstruction.

In vitro study.

Varying pressures were applied over the second and third cartilaginous rings of 10 pig tracheas in vitro and the anterior–posterior compression was measured.

At pressures of 257 mmHg, equivalent to the maximum possible pressure in the neck (i.e. systolic blood pressure), there was an average compression of 20.8 per cent of the original anterior–posterior tracheal diameter.

This study suggests that the pressures in haematomas observed after neck surgery would not be sufficient to cause airway obstruction due to direct pressure on the trachea. Therefore, the most likely cause of airway obstruction would be supraglottic oedema secondary to venous obstruction.

Patients who have undergone tracheoesophageal puncture for surgical voice restoration often use unnaturally high oesophageal air pressures during speech. This study examined the effect of high oesophageal air pressure on oesophageal body motility, lower oesophageal sphincter function and dyspeptic symptoms.

Cross-sectional study using several investigative tests of oesophageal function.

Sixteen patients who used tracheoesophageal fistula speech underwent several investigations, including: oesophageal manometry, videofluoroscopy, barium swallow, and tracheal pressure measurements during speech. The patients were also asked to complete a dyspepsia questionnaire.

We demonstrated that more than 50 per cent of these patients had subjective or objective disordered oesophageal function. Videofluoroscopy and manometry identified oesophageal dysmotility in the same patients.

Oesophageal function appears to be altered by tracheoesophageal fistula speech. However, our study showed that there is no contraindication to proceeding with tracheoesophageal fistula voicing even in patients with a history of oesophageal dysfunction.

We report an extremely rare case of congenital cholesteatoma affecting the occipital bone.

We present a case report, plus a review of the world literature on similar lesions.

This case report describes the presentation and treatment of a congenital cholesteatoma arising in an apparently unique location within the occipital bone, with no effect on middle-ear structure or function. The different imaging characteristics of this lesion are described and illustrated. The discussion centres on the differentiation of this lesion from intradiploic epidermoid cysts, more commonly described in the neurosurgical literature. The possible methods of pathogenesis are discussed, along with treatment suggestions.

Congenital cholesteatomas and intradiploic epidermoid cysts are indistinguishable both histologically and radiologically, and would appear to be the same disease.