Tolosa–Hunt syndrome is a rare condition of painful ophthalmoplegia combined with ipsilateral ocular motor nerve palsies, caused by non-specific granulomatous inflammation in the cavernous sinus, superior orbital fissure or orbit. A case of Tolosa–Hunt syndrome misdiagnosed as sinusitis orbital complication is reported.

A patient suffering from left periorbital pain, upper eyelid oedema and ptosis, and horizontal diplopia, diagnosed as sinusitis orbital complication, was referred to our department. Clinical evaluation revealed only a left VIth nerve paresis. Haematological studies, cerebrospinal fluid tests and computed tomography scanning were negative. A magnetic resonance imaging (MRI) scan showed enhancement of the left cavernous sinus. Corticosteroid therapy was commenced, and within three days all symptoms disappeared. A diagnosis of Tolosa–Hunt syndrome was made. Follow-up MRI studies were normal.

Tolosa–Hunt syndrome, although rare, is a nosological entity that otolaryngologists must bear in mind. Magnetic resonance imaging studies are essential in the diagnosis and follow up of these patients, in order to avoid a mistaken Tolosa–Hunt syndrome diagnosis.

Radiological imaging plays an indispensable, complementary role to endoscopy in the pre-therapeutic assessment of laryngeal cancer. We evaluated the reliability of radiological imaging in determining the extent of cancer and surgical resection, by comparing the results of pre-operative computed tomography and magnetic resonance imaging with those for post-operative pathological analysis.

Twenty-nine patients who had undergone laryngeal cancer surgery with a diagnosis of supraglottic cancer were reviewed. Imaging reliability was assessed for separate subunit regions of the supraglottic area, the glottic area and the cartilage.

The false diagnosis rate for all subunits was 25 per cent. The rate of false diagnosis associated with overstaging was 21 per cent. The rate of false diagnosis associated with understaging was 4 per cent.

In order to give the best chance of laryngeal preservation, especially in the case of false positive laryngeal subsites, computed tomography and magnetic resonance imaging should be combined with pre-operative endoscopy and intra-operative frozen section diagnosis.

‘Over-under’ myringoplasty is a versatile and effective surgical technique for tympanic membrane repair. The main drawbacks are possible trauma to the inner ear, due to manipulation of the malleus, and graft detachment from the apical portion of the malleus during the healing process, with consequent reduction of sound transfer function. To obviate these disadvantages, we have modified the over-under myringoplasty by maintaining anchorage of the tympanic membrane to the umbus.

A total of 78 umbus-anchored over-under myringoplasties were performed from 2004 to 2006 in 63 patients. After elevation of the tympanomeatal flap, the malleus was freed from the tympanic membrane in a superior to inferior direction, up to the region immediately superior to the umbus. A large graft with a radial slit was distended under the tympanic remnants and annulus, and the two tongues were positioned to surround the umbus area and overlapped under a non-perforated portion of the tympanic membrane.

Graft take was obtained in 71 ears (91 per cent). The auditory results showed an average residual air–bone gap of 6.7 dB, which was significantly better (p = 0.04) in comparison to that obtained in ears undergoing traditional over-under myringoplasty (11.9 dB).

Modification of the over-under myringoplasty by anchoring the graft to the umbus preserves both lever and catenary effects of the tympano-ossicular system, reduces traumatising manoeuvres during dissection of the tympanic membrane from the malleus, and yields excellent results in terms of graft take and auditory outcome.

To demonstrate the importance of pre-operative ear, nose and throat assessment in patients undergoing endoscopic, transsphenoidal surgery for pituitary tumours.

Literature pertaining to the pre-operative otorhinolaryngological assessment and management of patients undergoing endoscopic anterior skull base surgery is sparse. We describe two cases from our series of 59 patients undergoing endoscopic pituitary surgery. The first case involved a young male patient with a large pituitary macroadenoma. His main complaint was visual impairment. He had no previous history of sinonasal pathology and did not complain of any nasal symptoms during the pre-operative neurosurgical assessment. At the time of surgery, a purulent nasal discharge was seen emanating from both middle meati. Surgery was abandoned due to the risk of post-operative meningitis, and postponed until the patient's chronic rhinosinusitis was optimally managed. The second patient was a 47-year-old woman with a large pituitary macroadenoma, who presented to the neurosurgical department with a main complaint of diplopia. She too gave no history of previous nasal problems, and she underwent uneventful surgery using the endoscopic, transnasal approach. Two weeks after surgery, she presented to the emergency unit with severe epistaxis. A previous diagnosis of hereditary haemorrhagic telangiectasia was discovered, and further surgical and medical intervention was required before the epistaxis was finally controlled.

Pre-operative otorhinolaryngological assessment is essential prior to endoscopic pituitary or anterior skull base surgery. A thorough otorhinolaryngological history will determine whether any co-morbid diseases exist which could affect the surgical field. Nasal anatomy can be assessed via nasal endoscopy and sinusitis excluded. Computed tomography imaging is a valuable aid to decisions regarding additional procedures needed to optimise access to the pituitary fossa.

Within the field of otorhinolaryngology, interest in facial plastic surgery has grown significantly in recent years. There is a lack of evidence in the literature documenting this interest in the British Isles.

572 questionnaires were mailed to all members of the British Association of Otolaryngologists, Head and Neck Surgeons and to members of the Irish Otolaryngological Society.

Our response rate was 68 per cent. One-third of respondents were performing facial plastic procedures regularly, most commonly otoplasty (80 per cent), rhinoplasty (74 per cent) and facial flaps (28 per cent). Two-thirds of respondents had attended supplementary courses in facial plastic surgery, and 65 per cent would like facial plastic surgery to compose one-third of their daily practice.

Facial plastic surgery has become a significant part of the otorhinolaryngologists' practice. They are now offering a wider variety of procedures in the area. This is the first paper to document this interest in the United Kingdom and Ireland.

Vocal results after endoscopic cordectomy have not yet been well defined. The aim of this study was to assess the vocal function of patients who had undergone CO2 laser cordectomy.

Retrospective, observational and control group study, conducted in a tertiary care medical department.

One hundred and thirty-five male patients (age range 36–83 years) underwent different types of endoscopic cordectomy. Forty age-matched, euphonic male subjects were selected as controls. Patients were classified according to the main site of the phonatory neo-glottis. Outcome measures were maximum phonation time, vocal intensity and harmonic/noise ratio. Mann–Whitney and rank Spearman tests were used for statistical analysis.

Findings indicated statistically significant differences for all parameters, comparing patients and controls (p<0.001), and a direct positive relation between type of functional compensation and outcome measures in the study patients (p<0.001).

The results indicate that functional compensation and outcome measures were related, and that no functional compensation enabled the study patients to achieve a voice quality comparable with that of controls.

We present the case of a 59-year-old Chinese patient with an unusual presentation of mucosal plasmacytosis involving the oropharynx, related to the use of toothpaste.

Case presentation and review of English medical literature involving mucosal plasmacytosis.

Mucosal plasmacytosis is an uncommon disease process and has been associated with hypersensitivity reactions. Most cases involve the gingival mucosa, although there have been reports of cases involving other oral mucosal sites and the upper aerodigestive tract. Our case provides an example of oropharyngeal plasmacytosis related to toothpaste. A resolution of signs and symptoms followed withdrawal of the suspected allergens.

Mucosal plasmacytosis is a benign inflammatory process that may appear to be more sinister on clinical examination. Skin patch testing is a useful adjunct in confirming the diagnosis.

Spontaneous fracture of the maxillary sinus is usually associated with enophthalmos and pre-existing sinus disease.

We present a case of spontaneous maxillary sinus fracture without enophthalmos and with no preceding history of trauma or evidence of sinusitis.

The closest condition to that presented is silent sinus syndrome. The differences between our case and this syndrome are reviewed. There are no previously reported cases of lateral wall maxillary fracture and associated facial surgical emphysema following nose-blowing.

Primary distal renal tubular acidosis with sensorineural hearing loss is a rare autosomal recessive disease, usually caused by mutations in the ATP6V1B1 gene. The aim of this study was to characterise the phenotype of this disease, with emphasis on the auditory findings, in a cohort of Israeli children.

Prospective study of five children, from three unrelated families, with distal renal tubular acidosis and bilateral sensorineural hearing loss, with mutations in the ATP6V1B1 gene.

The following were collected from patients' medical records: biochemical and renal data, age at distal renal tubular acidosis diagnosis, and age at hearing loss. Hearing loss progression as well as current hearing status were assessed, and high resolution computed tomography of the temporal bone was performed. All patients underwent genetic testing.

Four patients were diagnosed with distal renal tubular acidosis before the age of six months and one at 24 months. All had the classical findings of low blood pH and inappropriately high urine pH. Hearing loss was diagnosed between the ages of three months and two years. The hearing loss was bilateral, asymmetrical and progressive, occasionally with a conductive component. Two children underwent cochlear implantation, at ages 10 and 15 years. High resolution computed tomography, performed in four patients between the ages of 2.5 and 15 years, showed bilaterally enlarged vestibular aqueducts. This was the only radiological abnormality in the inner ear in all cases. A different mutation in the ATP6V1B1 gene was found in each family.

Several types of mutations in the ATP6V1B1 gene may cause distal renal tubular acidosis and sensorineural hearing loss. Patients display a typical progressive type of hearing loss and have enlarged vestibular aqueducts, with no other abnormalities being observed on imaging.

We present a case of systemic lupus erythematosus with symptomatic sensorineural hearing loss which was successfully treated with azathioprine, as assessed both clinically and radiologically. We also present a review of the relevant literature.

A woman with systemic lupus erythematosus presented with sensorineural hearing loss, initially on the right and subsequently developing on the left over several months. An audiogram revealed profound neurosensory hearing loss bilaterally. The patient was treated with prednisone 60 mg daily and azathioprine 200 mg daily. An improvement on the left was noted on follow-up audiography as well as on magnetic resonance imaging of the internal auditory canals and surrounding structures.

Sensorineural hearing loss has been described in autoimmune disorders but is rare. Aural symptoms have been described, with varying incidences (0–57.5 per cent), in systemic lupus erythematosus. However, symptomatic sensorineural hearing loss is rare in systemic lupus erythematosus. Prednisone appears essential when an immunological or vasculitic cause is found. The use of azathioprine should be considered, as well as follow-up with magnetic resonance imaging to detect improvement.

The management of laryngotracheal stenosis is still a serious surgical challenge. The fact that there are currently numerous reconstruction procedures indicates that there is at present no standard treatment.

Titanium mesh was used instead of traditional homografts in reconstruction of the anterior laryngotracheal wall in 12 tracheostomised patients with benign chronic laryngotracheal stenosis. The anterior laryngotracheal wall was split, followed by excision of scar tissue and fixation of the titanium plate at the split end. A Silastic® stent was inserted above the tracheostomy tube and fixed in place by running sutures fixed to the skin by buttons. The stent was removed endoscopically six weeks later and a trial of decannulation was undertaken.

Endoscopically, good epithelisation was seen on the inner surface of the mesh in 10 cases and decannulation was possible. Four of these patients required endoscopic debulking of granulation tissue. Decannulation was impossible in two cases, one due to excessive granulation tissue and the other due to prolapse of the titanium mesh into the tracheal lumen (the mesh was removed endoscopically and a Montgomery T-tube inserted).

Titanium mesh was found to be a good alternative for augmentation of the anterior laryngotracheal wall. It offered rigid support, with fewer of the complications reported with other grafts.

To measure the thermal properties of operative endoscopes used in otorhinolaryngological practice.

A series of endoscopes of varying diameters and angulations were attached to a light source and temperature measurements taken of their shaft and tip; a measurement was also taken 5 mm in front of the endoscope tip.

Temperature changes took place rapidly. The amount of heat produced by the endoscopes was maximal at the tip, with larger diameter endoscopes attaining a higher temperature. Temperatures on the shaft and in front of the tip reached relatively constant temperatures independent of the type of endoscope. The maximum temperature achieved was 104.6°C for the 4 mm, 0° endoscope. Cooling occurred rapidly after the light source was switched off.

The heat produced by some endoscopes is sufficiently great to cause thermal injury to tissues. Awareness of the temperatures produced by these endoscopes should prompt clinicians to actively cool their endoscopes during a procedure, before any thermal injury is caused.

Inner-ear malformations are frequently found in patients with sensorineural hearing loss. However, isolated anomalies of the vestibular part of the inner ear are seldom described, and for this reason their impact on balance is poorly understood.

We present the case of a 38-year-old Caucasian man with recurrent vestibular complaints, with a sensation of linear tilting, but no hearing impairment. Clinical and neuro-otological examinations showed peripheral involvement of the vestibular system, while audiological investigation was within normal limits. High-resolution magnetic resonance imaging of the inner ear, with three-dimensional reconstruction, demonstrated isolated vestibular anomalies involving both the lateral semicircular canal and the utricle.

Bearing in mind this case, we speculate that isolated vestibular malformation may not be as rare as previously thought, and should be investigated with the aid of sophisticated imaging techniques. A review of the relative literature, focussing attention on the molecular aspects, is also reported.

To describe a previously unreported syndrome of recurrent syncopal attacks provoked by light stimulation of the external auditory canal.

A 13-year-old girl had been receiving treatment for presumed absence seizures, with inadequate treatment response. Imaging was normal. Careful history taking indicated that the recurrent syncopal attacks were precipitated by external auditory canal stimulation. Targeted autonomic function tests confirmed a hyperactive vagal response, with documented significant bradycardia and lightheadedness, provoked by mild stimulation of the posterior wall of the left external auditory canal. Abstinence from ear scratching led to complete alleviation of symptoms without any pharmacological treatment.

Reflex syncope consequent to stimulation of the auricular branch of the vagus nerve is proposed as the pathophysiological mechanism for this previously undocumented syndrome.

To conduct a prospective study (1) to evaluate and compare the efficacies of nasopharyngeal endoscopy and computed tomography in the diagnosis of local failure of external beam radiotherapy for nasopharyngeal carcinoma, and (2) to assess whether multiple endoscopic nasopharyngeal biopsies are superior to a single, targeted biopsy, for the same purpose.

Forty-six patients who had been treated with external beam radiotherapy for primary nasopharyngeal carcinoma were enrolled in the study. For every patient recruited, computed tomography, rigid nasopharyngeal endoscopy and nasopharyngeal biopsies were performed 12 weeks after radiotherapy.

Twelve weeks after treatment, six patients (13 per cent) had evident disease on histological examination of biopsies. Nasopharyngeal endoscopy showed a sensitivity, specificity, positive predictive value and negative predictive value of 66.6, 95, 66.6 and 95 per cent, respectively. There was statistically significant agreement between the endoscopic findings and the histological findings (Kappa reliability coefficient = 0.617, p < 0.01). Computed tomography showed a sensitivity, specificity, positive predictive value and negative predictive value of 50, 45, 12 and 85.7 per cent, respectively. There was no statistically significant agreement between the computed tomography findings and the histological findings (Kappa reliability coefficient = 0.021, p > 0.05). A targeted, single biopsy performed under endoscopic control demonstrated excellent sensitivity, specificity, positive predictive value and negative predictive value, being 83.3, 100, 100 and 97.5 per cent, respectively. The Kappa test showed a very statistically significant agreement between the histological findings for the single and the multiple endoscopic biopsies (Kappa reliability coefficient = 0.897, p < 0.001).

Rigid nasopharyngeal endoscopy should be considered the primary follow-up tool after radiotherapy treatment of nasopharyngeal carcinoma, with computed tomography being reserved for patients with histological or symptomatic indications. Routine postnasal biopsies are not necessary, given the excellent specificity and negative predictive value of rigid nasopharyngeal endoscopy. Single, targeted endoscopic biopsy provides an excellent alternative to the usual multiple biopsies. In addition, it reduces cost, time, morbidity and patient discomfort.

Tracheoesophageal puncture is recognised as an effective and reliable method for voice restoration following total laryngectomy. Several techniques have been described, ranging from rigid oesophagoscopy under general anaesthesia to more recent endoscopic techniques utilising intravenous sedation or local anaesthetic. We describe our technique for secondary tracheoesophageal puncture utilising unsedated transnasal oesophagoscopy in an office setting.

Retrospective review of all total laryngectomy patients undergoing in-office transnasal oesophagoscopy-assisted tracheoesophageal puncture between October 1 2004 and December 31 2006.

Eleven patients undergoing transnasal oesophagoscopy-guided tracheoesophageal puncture were identified. Successful tracheoesophageal puncture placement was achieved in 10 of 11 patients (91 per cent). In one patient tracheoesophageal puncture could not be performed due to anatomic constraints. One patient had bleeding from the puncture site requiring silver nitrate cautery. All patients tolerated the procedure well. Voice results were satisfactory in all cases.

Transnasal oesophagoscopy-guided tracheoesophageal puncture provides a simple, safe option for secondary voice rehabilitation in laryngectomy patients.