Objectives: ‘Choose and Book’ is a UK government initiative devised to allow a greater freedom of choice for National Health Service patients. The system is designed to give patients a choice of hospitals and appointment times, as well as giving their general practitioner (GP) more responsibility for appropriate prioritization. We set out to determine the attitudes of UK GPs to the new Choose and Book project and to assess the impact that these changes are likely to have on ENT practice.

Design: Postal questionnaire survey.

Methods: Five hundred GPs were sent a questionnaire about the planned Choose and Book referral project.

Results: Three hundred and eighty GPs (76 per cent) replied to the questionnaire after reminders were sent. Most were aware of the project and had been sent information about it. Of those who had heard of it, 61.5 per cent did not think it was a good thing. Most stated that both they and their patients were satisfied with current prioritization practices. Many GPs would be willing to delegate responsibility for prioritization to non-clinical staff. Important time and responsibility issues were identified.

Conclusions: The majority of GPs were not in favour of Choose and Book. Many cited difficulties with time constraints and an inflexible system as factors that made Choose and Book unacceptable.

Background: Frequent active opening of the eustachian tube (ET) allows ventilation of the middle ear and equilibration of pressure changes. Active opening is accomplished by the contraction of the paratubal muscles during swallowing. Because a disturbance of the ventilatory function of the ET may contribute to the development of otitis media with effusion, it is important to investigate ET function. Sonotubometry can be used to detect whether the ET can open or not during swallowing acts.

Methods: We developed a sonotubometer to test ET ventilatory function in 36 healthy adults. The width of the test signal frequency was between 5500 and 8500 Hz (centre frequency of 7000 Hz) and the loudness was 95 dB. To test reproducibility, testing took place in two sessions of 10 swallowing acts each.

Results: Opening of the ET could be registered in 91.6 per cent of the subjects in at least one of the two measurements. The first and the second measurements were highly correlated, with a Spearman's coefficient of 0.907.

Conclusion: We confirmed that there is generally a good ventilatory ET function in otologically healthy adults, although, in a few cases, ET opening was not registered. Furthermore, we confirmed that our sonometric test equipment had acceptable reproducibility. Sonotubometry is a promising method for assessing ventilatory ET function. Research is ongoing to test the discriminative power of sonotubometry in children with various otological conditions.

Objective: To evaluate the relationship between disease stage and duration of symptoms for squamous cell carcinoma of the larynx.

Method: We evaluated retrospectively data from 102 laryngeal squamous cell carcinoma patients seen in the otorhinolaryngology department of the Gazi University School of Medicine between December 1996 and June 2004. Inclusion criteria were a histologic diagnosis of laryngeal squamous cell carcinoma, no previous medical, surgical or radiological treatment for carcinoma, and the absence of any other primary tumours or distant metastatic disease.

Results: There was no relationship between duration of symptoms and stage of the disease, both for glottic and supraglottic tumours. When glottic and supraglottic tumours were compared, no significant difference in symptom duration could be found.

Conclusion: There is no correlation between symptom duration and the stage of the disease for squamous cell carcinoma of the larynx. Therefore, symptom duration does not reflect the stage of the tumour.

The administration of anaesthetic gases to an infant undergoing an endolaryngeal laser procedure can be difficult. We describe the use of a Magill's nasal sucker and an anaesthetic connector to maintain anaesthesia during laser surgery.

We describe a simple technique of replacement Montgomery T-tube insertion in a closed neck under general anaesthetic.

The objectives of this study were to determine (1) the rates of complications, admissions to hospital and requirements for further surgery in patients fitted with tracheoesophageal fistula speech valves, and (2) whether any factors were predictive of complications. A case note review was undertaken of all patients undergoing a laryngectomy at Gartnavel General and Stobhill Hospitals over a 10-year period. One hundred patients were identified.

Forty-five patients had complications from their valves, most commonly granulation tissue formation. Thirty-five had a least one admission related to complications and 34 required further surgery. Sixty-seven were vocalizing with the valve.

Radiotherapy and valve type were not statistically significant in predicting complications in this study. Primary puncture was associated with a higher rate of complications, although the numbers undergoing secondary puncture were small.

Aortitis and saddle nose deformity are extremely unusual manifestations of a variety of systemic diseases. The concurrent appearance of these apparently disparate clinical features is a clinical rarity. A case of saddle nose deformity in a patient with confirmed Takayasu's arteritis is presented. The relevant literature is reviewed with reference to the possible differential diagnosis of patients with aortitis and saddle nose deformity.

Intracranial penetrating injury through the nose is uncommon. We present the case of a four-year-old girl who sustained a transnasal, intracranial penetrating injury with a sharp wooden object. We performed endoscopic removal of the foreign body and repair of the associated cerebrospinal fluid fistula.

Ring graft is a modified cartilage-perichondrium composite graft (CPCG) with only a peripheral ring shaped cartilage. In this series, tympanic membrane perforations were repaired using (ring graft) during treatment of 18 cases of non-cholesteatomatous chronic suppurative otitis media (CSOM).

This study showed that ring graft has the advantages of both CPCG and perichondrial graft but without their disadvantages. Complete closure of the perforations was achieved in all cases without delay in hearing improvement.

It is recommended to use the ring graft whenever needed to repair central tympanic membrane perforations even with difficult anterior or total perforations.

Introduction: Goitre presenting with acute, life-threatening airway compromise is an uncommon indication for thyroid surgery. The management of this critical condition is controversial.

Aims: To investigate the incidence of life-threatening airway compromise in patients with benign goitre, to investigate the predisposing factors, and to outline an optimal management policy for such critical cases.

Methods: Retrospective review of the medical records of patients presenting with life-threatening, acute airway compromise secondary to benign thyroid disease, treated by the senior author (CT) between July 1994 and July 2005.

Results: Of a total of 505 thyroid surgery procedures over the 11-year period, five patients with benign thyroid disease had presented with life-threatening, acute airway compromise. Three of the five patients had been thyrotoxic and two of these had received an iodine load prior to airway compromise. Immediate endotracheal intubation for airway control followed by admission to the intensive care unit had been the presentation in two patients. An incidental diagnosis of tracheal compression had been made from the computed tomography (CT) scan in two patients who had non-resolved obstructive airway disease. Emergency thyroidectomy had been performed in all five patients. Significant tracheomalacia had been noted in four patients. Following thyroidectomy, two patients had required tracheostomy and one had required tracheal stenting.

Conclusion: Chronic obstructive airways disease, substernal extension and long-standing goitre are considered as risk factors for developing acute, life-threatening airway compromise in the presence of benign thyroid disease. A recent iodine load may lead to airway compromise in thyrotoxic patients. A CT scan is indicated in cases of unresponsive chronic obstructive airways disease to rule out substernal extension of non-palpable goitres. Life-threatening airway compromise secondary to benign goitres is best treated by endotracheal intubation if conservative measures fail, followed by emergency thyroidectomy. Following surgery, close observation is mandatory to exclude airway compromise due to tracheomalacia and laryngeal oedema.

Objectives: Recent studies have shown that the spiral computed tomography (CT) scan is a sensitive imaging modality for predicting neoplastic invasion of thyroid cartilage. The objectives of our study were: to assess the accuracy of pre-operative spiral CT in predicting thyroid cartilage involvement in patients with carcinoma of the larynx; and to elucidate the factors that would accurately indicate cartilage involvement.

Material and methods: Medical records, including spiral CT scans and pathological reports, were reviewed for 27 patients who had undergone laryngectomy in two major hospitals in south Wales. A consultant radiologist with special interest in cross-sectional imaging re-evaluated the scans to assess neoplastic involvement of the thyroid cartilage, based on definite, objective criteria. These criteria included: soft tissue asymmetry; loss of medullary space; spiky or irregular surface; distortion of cartilage framework; and abnormal soft tissue on both sides of the cartilage. The radiological findings were then correlated with the histopathological evidence of cartilage invasion by the tumour.

Results: Out of the 27 cases, 15 had evidence of histological invasion of thyroid cartilage. The most specific criterion to predict thyroid cartilage involvement was the presence of tumour on both sides of the cartilage (specificity of 91 per cent, sensitivity of 66 per cent). Combining two criteria increased both the sensitivity and the specificity to 86 and 91 per cent, respectively.

Actinomycotic infections of the cervicofacial region are not uncommon. However, actinomycosis of the tongue is rare. A mass that may mimic both benign and malignant neoplasms can be seen at clinical presentation and may mislead the diagnosis.

We report a patient who presented with a tumour-like tongue mass causing speech disturbance, diagnosed as actinomycosis.

We describe a new technique for inserting grommets which is both easy to master and provides better visualization of the tympanic membrane. This is particularly helpful in patients with narrow ear canals.

The parathyroid glands are small, inconspicuous, and variable in number, colour and position. Their identification is vital for excision of hyper-functioning glands and for preservation of normally functioning ones in patients undergoing thyroidectomy.

Intravenous infusion of methylene blue at a dose of 7.5 mg/kg is commonly used to aid visualization of the parathyroid glands intra-operatively. Methylene blue is generally considered benign, and there are only two cases published in the literature reporting toxicity following intravenous infusion – such toxicity is a diagnosis of exclusion.

We report a case of methylene blue toxicity resulting in expressive aphasia, confusion and disinhibition following infusion for parathyroid adenoma localization. The patient made a complete recovery over 48 hours. Methaemoglobinaemia was excluded as a cause. We suggest that the mechanism of toxicity was a direct effect of methylene blue, although an adverse interaction with serotonin re-uptake inhibitors could not be excluded.

In keeping with the UK National Poisons Information Service recommendations, we have altered our practice and now use methylene blue at a dose not exceeding 4 mg/kg. This has not affected our success rate for identification of parathyroid glands. We report this case to highlight the rare occurrence of methylene blue toxicity when used at a dose of 7.5 mg/kg.

Proteus syndrome is a rare and highly variable hamartomatous syndrome that can affect multiple organ systems. It is characterized by hyperplasia of connective tissue, vascular malformations, epidermal naevi and hyperostosis. Most of the cases present to plastic and orthopaedic surgeons. Otolaryngologic presentations are minimal. We report such a rare case, which presented with a huge unilateral tonsillar mass causing dysphagia.

The biological changes in recurrent laryngeal cancer following radiotherapy are not fully understood. The authors investigated differences in the expression of p53, proliferating cell nuclear antigen (PCNA) and bcl-2 in laryngeal cancer specimens before radiotherapy and in recurrent laryngeal cancer specimens following radiotherapy in the same patients. The authors investigated the expression of p53, PCNA and bcl-2 by immunohistochemical stain in 30 specimens from 15 patients with primary laryngeal cancer and recurrent laryngeal cancer after radiotherapy.

The expression of p53 protein was significantly different in laryngeal cancer before radiotherapy (4/15, 26.7 per cent) compared with recurrent laryngeal cancer after radiotherapy (8/15, 53.3 per cent) (p < 0.05). The PCNA index was also significantly different in laryngeal cancer specimens before radiotherapy (mean, 11.9 per cent) compared with recurrent laryngeal cancer after radiotherapy (mean, 18.0 per cent) (p < 0.05). However, there was no statistically significant alteration of bcl-2 expression in primary compared with recurrent laryngeal cancer. The expression of p53 and PCNA increased in recurrent laryngeal cancers after radiotherapy, compared with that in laryngeal cancers before radiotherapy. Recurrent laryngeal cancers arising following radiotherapy became biologically aggressive.

Angiofibromas rarely localize in extranasopharyngeal sites. The most common site for extranasopharyngeal angiofibromas is the maxillary sinus. The ethmoid and sphenoid sinuses, nasal septum, middle and inferior turbinates, conjunctiva, molar and retromolar region, and larynx are other sites where extranasopharyngeal angiofibromas have been reported. Only one case of buccal extranasopharyngeal angiofibroma has been reported to date. We present a case of buccal extranasopharyngeal angiofibroma that was excised completely following embolization and we also review the literature.

A case is presented of a nine-month-old male infant who presented acutely with an anterior neck and mediastinum mass compressing the trachea. Radiological assessment by ultrasound, magnetic resonance imaging and computed tomography suggested the nature of the mass to be a lymphatic malformation (cystic hygroma). The excised specimen was revealed as a mature teratoma. The inability to distinguish between lymphatic malformation and teratoma on multi-imaging modalities confers a risk of mismanaging these lesions with the use of sclerotherapy; surgical excision is the necessary treatment. The potential consequences are discussed.

We present a novel method of aspirating a peritonsillar abscess in a patient with severe trismus. In our experience, this method is efficient, allows good access to the peritonsillar area and facilitates rapid resolution of the trismus before definitive drainage can be performed.

Infection with methicillin-resistant Staphylococcus aureus (MRSA) is increasing. It may be community or hospital acquired and is characteristically difficult to eradicate. Here we report a case of a two-year-old girl who sustained a traumatic tympanic membrane perforation following a minor burns injury. She was seen as an out-patient in a burns unit and subsequently developed MRSA otorrhoea. This was treated with a two-week course of fusidic acid topical drops. At three-week follow up the tympanic membrane had healed and the infection had healed completely. Fusidic acid is safe and effective in the treatment of MRSA otorrhoea. We need to maintain vigilance in the treatment of otorrhoea, as MRSA may become an increasingly common pathogen in the future.