Training in Endoscopic Ear Surgery: A Scoping Review

OBJECTIVE

Despite the increasing popularity of Endoscopic Ear Surgery (EES), there is a lack of evidence to guide trainees as they introduce EES into practice. This review aims to evaluate training in EES including the optimal introductory procedures, methods of training, the learning curve, and the determination of competency in EES. In addition, this review seeks to identify any areas falling within these themes requiring further clarification.

DATA SOURCES

A database search of Pubmed, Embase and the Cochrane Library was conducted in June 2022. Original articles, systematic reviews, and meta-analyses reporting on training in EES, introduction into practice, learning curves, and competency assessment were included.

REVIEW METHODS

A scoping review was carried out in accordance with the Joanna Briggs Institute guidelines and reported according to PRISMA guidelines for scoping reviews. A qualitative assessment of results grouped thematically was performed.

RESULTS

Twenty-eight studies met the inclusion criteria, with 24 rating as "fair" or "good" on quality assessment. Surgical simulation was the most frequently described method of training as utilized in 11 studies. The most suggested introductory procedure was tympanoplasty which was advocated for in five studies. Heterogeneity existed in the outcomes and methodologies used to measure EES learning curves, with an overreliance on surgical times. No robust definition of competency in EES procedures exists at present.

CONCLUSIONS

Surgical simulation appears to be a beneficial training methodology for EES. However, there is a marked lack of objective data to describe the optimal introductory procedures or assessment of competency in EES. Laryngoscope, 133:3269-3278, 2023.

Trans-canal tragal cartilage myringoplasty; a comparative analysis of endoscopic and microscopic approaches

BACKGROUND

The advent of Endoscopic Ear Surgery (EES) has allowed otologists an improved view of the surgical field compared with conventional Microscopic Ear Surgery (MES). EES presents different challenges for surgeons and a learning curve is necessary.

AIMS

The purpose of this study was to compare the efficacy of EES and MES for trans-canal tragal cartilage myringoplasty, an entry level EES.

METHODS

We retrospectively analysed patients who underwent push through trans-canal tragal cartilage myringoplasty in our institution over 5 years (2016-2020). Exclusion criteria were: patients with prior ear surgery, non-tragal cartilage tympanic membrane graft, additional procedure at time of surgery and patients with insufficient follow up. EES and MES groups were compared using outcomes such as graft success rate, changes in pure tone audiometry (PTA), operative time and complications.

RESULTS

Seventy-four patients met inclusion criteria (MES = 38, EES = 36). Mean age of included patients was 29.3 years with no significant demographic differences between groups. Graft success rate at 12 months was higher among the EES group versus MES (94.4% v 86.8%, p = 0.43). Mean operative time was reduced in the EES group (47.3 min v 53.8 min, p = 0.04). Hearing outcomes did not differ significantly between groups. No major operative complications occurred in either group.

CONCLUSIONS

Outcomes were marginally better in the cohort who underwent EES. This supports that EES offers an otologic choice to complement established practice for trans-canal myringoplasty and may be used to facilitate introduction to EES for trainees and otologists wishing to learn this technique.

Measuring the Angular Accuracy of a Clinician-Performed Epley Maneuver Used to Treat Benign Paroxysmal Positional Vertigo

INTRODUCTION

Particle repositioning maneuvers have become the criterion standard for managing benign paroxysmal positional vertigo. The Epley canalolith repositioning maneuver is used to treat posterior canal benign paroxysmal positional vertigo and is successful in up to 90% of cases. However, when performed, there are many clinician variabilities, and angles are approximate. It is not known how accurate each angle needs to be for the target canal to be adequately stimulated. The objective of this study was to measure the angular accuracy of clinician-guided Epley maneuvers using a three-axis accelerometer.

METHODS

Ten healthy subjects were recruited; participants had no known audio vestibular pathology. Five right-hand-dominant clinicians performed Epley maneuvers on both ears of two different participants. Twenty maneuvers were carried out in total. Angular movements were recorded using a vestibular feedback electronic device, the SHIMMER accelerometer. Data were recorded and analyzed using the EYESWEB Open Platform.

RESULTS

Results showed that there was angular error at every stage of the clinician-performed Epley maneuver. The most accurate movement was positioning the head to the left of 45 degrees for a left ear maneuver with an average error of 2.94 degrees. The least accurate was when positioning the patient to face the floor at 135 degrees from supine for a right ear maneuver with an average error of 17.6 degrees.

CONCLUSION

Even when experienced ENT clinicians perform a standard Epley maneuver, there is a wide range of angular inaccuracy at each stage. Face to floor is particularly inaccurate. However, given that a majority of procedures (90%) work on the first attempt, there must be an acceptable but unknown range of angular inaccuracy. Novel technologies could improve the angular accuracy, potentially give better results, and allow a broad range of individuals to perform a more accurate Epley maneuver.

Radiomic Detection of Malignancy within Thyroid Nodules Using Ultrasonography-A Systematic Review and Meta-Analysis

Background: Despite investigation, 95% of thyroid nodules are ultimately benign. Radiomics is a field that uses radiological features to inform individualized patient care. We aimed to evaluate the diagnostic utility of radiomics in classifying undetermined thyroid nodules into benign and malignant using ultrasonography (US). Methods: A diagnostic test accuracy systematic review and meta-analysis was performed in accordance with PRISMA guidelines. Sensitivity, specificity, and area under curve (AUC) delineating benign and malignant lesions were recorded. Results: Seventy-five studies including 26,373 patients and 46,175 thyroid nodules met inclusion criteria. Males accounted for 24.6% of patients, while 75.4% of patients were female. Radiomics provided a pooled sensitivity of 0.87 (95% CI: 0.86−0.87) and a pooled specificity of 0.84 (95% CI: 0.84−0.85) for characterizing benign and malignant lesions. Using convolutional neural network (CNN) methods, pooled sensitivity was 0.85 (95% CI: 0.84−0.86) and pooled specificity was 0.82 (95% CI: 0.82−0.83); significantly lower than studies using non-CNN: sensitivity 0.90 (95% CI: 0.89−0.90) and specificity 0.88 (95% CI: 0.87−0.89) (p < 0.05). The diagnostic ability of radiologists and radiomics were comparable for both sensitivity (OR 0.98) and specificity (OR 0.95). Conclusions: Radiomic analysis using US provides a reproducible, reliable evaluation of undetermined thyroid nodules when compared to current best practice.

The psychological impact of COVID-19 on ear, nose and throat (ENT) specialists

Introduction

Ear, nose and throat (ENT) specialists are a high-risk group for COVID-19. Although the implications of SARS-CoV-2 infection on physical health are well-documented, the psychological impact is frequently overlooked.

Aims

The aim of this study was to gauge the psychological impact of COVID-19 on ENT specialists in Ireland.

Methods

A national, cross-sectional, web-based survey was distributed to ENT specialists during the peak of the COVID-19 pandemic (21^st May 2020–21^st June 2020). The questionnaire collected sociodemographic and COVID-19 related data. The GAD-7 was utilized to measure symptoms of clinically significant anxiety disorder.

Results

Thirty-eight ENT specialists (M/F:24/12, median age, 38.7 years (23–60 years)) completed the survey. About 34% (n = 13) of participants screened positive for an anxiety disorder, of which 2 (5%) had moderate symptoms. The majority of participants (n = 32, 84%) felt ENT specialists had increased exposure to SARS-CoV-2 compared with other medical specialties. Additionally, 32% (n = 12) felt incapable of protecting themselves from infection. An encouraging proportion of ENT specialists (n = 22, 58%) were aware of psychological support available from national and institutional organizations.

Conclusions

The long-term psychological sequelae of COVID-19 will be felt as the physical burden eases. As we adjust to new normalities, ENT surgeons must be conscientious of the mental health issues that arise from the working environment. Sources of anxiety emanated from a lack of control over infection risk, increased vulnerability to COVID-19 relative to other specialties and the implications this has for ENT specialists and their families. Future interventions must focus on increasing awareness of the available psychological support services for our healthcare workers.

Human Papilloma Virus- Associated Head and Neck Cancer: A 21st Century Pandemic; Assessing Student Awareness and Knowledge

Background The Human Papillomavirus (HPV) is a causal agent in a subset of Head and Neck Cancers (HNC) being diagnosed in younger patients without significant tobacco and alcohol use. This survey assessed the awareness level of HNC and HPV vaccinations in university students. Methods An anonymous, questionnaire-based survey of registered students of the National University of Ireland, Galway (NUIG) was carried out. Results 1,550 responded, 1,494 completed the survey; 1,018 female (68.1%), 476 male (31.9%). 63% had never heard the term HNC. 45% had never heard the term HPV. 69% were unaware of how one would be exposed to HPV. 84% were unaware of the association between HNC and HPV. Conclusions There are poor levels of awareness of HNC, HPV and HPV vaccination. HPV vaccination needs to be appreciated as a major cancer breakthrough. However the public health benefits of increased awareness of HPV, HNC and HPV vaccination have yet to be realised.

A Series of Oral Lesions Presenting to an Otolaryngology Department

This study was performed to assess the incidence and intraoral distribution of different mucosal lesions in a representative population. Retrospective review of clinical notes and assessment of histology reports of patients were performed, who presented with different oral lesions to University Hospital Galway, between January 2007 and December 2008.Of the 106 histology reports evaluated, 94 were identified as benign lesions while 12 were malignant lesions. 96 of these patients were referred from G.P services, 6 patients were referred from other departments while 4 patients came through emergency department by self referral. The numbers and incidence of the commonest lesions in order of frequency were chronic inflammation 20 (18.8%), papilloma 19 (17.1%), fibroma 09 (8.4%), mucocele 09 (8.4%) and leukoplakia 08 (7.5%).We concluded that majority of the presented oral lesions are benign (88.%). Chronic inflammation (18.8%) is the commonest benign oral lesion and all white lesions which represents 34% of oral lesions are not true leukoplakia.

Day-case tonsillectomy: practical solution or practical impossibility

The use of day case surgery is on the rise. In order to improve efficiency and reduce cost, it has been proposed that tonsillectomy could be undertaken as a day-case procedure in Ireland. A retrospective, chart-based study was carried out. The medical and social criteria of all patients who underwent tonsillectomy during a twelve-month period were evaluated. Individual, local and national factors were identified and international comparisons were made. Of 161 patients included, 43 (27%) were considered suitable for day case tonsillectomy (DCT). The distance/time criteria from hospital excluded 64% of patients. The diagnosis of obstructive sleep apnoea was the single most common medical reason for exclusion. Support structures were deficient. Local factors must be considered before any policy or targets are developed for DCT. Patient safety is the fundamental tenet. Currently, the infrastructure and the support required for a patient-focused, safe efficient DCT are deficient, and need investment.

Newborn hearing screening: a regional example for national care

Congenital Permanent Childhood Hearing Impairment (PCHI) is known to have a negative effect on language acquisition, cognitive development and social integration. Since 2000 our department has implemented a UNHS program in the West of Ireland. We describe our experience and detail our results to date. All neonates born from October 2000 to November 2007 were screened using a 2-stage protocol. Transient evoked oto-acoustic emissions (TEOAEs) were used to screen all neonates, followed by automated auditory brainstem response (AABR) in those who did not pass TEOAE, and all neonates at audiological risk. 26,281 babies were born over the eight year period. 25,742 underwent the screening process, achieving a coverage rate of 98%. The prevalence of PCHI in the population tested was 1.21/1000 live births (31/25,731). Our results show that a hospital based 2-stage UNHS protocol using TEOAEs and AABR is accurate, feasible and effective.

Public knowledge of head and neck cancer

Studies show 60% of patients with newly diagnosed Head & Neck Squamous Cell Cancer in Ireland, present with advanced disease. A poor level of knowledge and awareness among the public of Head & Neck Cancer, is an important consideration in the often delayed presentation for medical attention in many of these cases. Our study surveyed 200 members of the public to assess their knowledge and awareness of Head & Neck Cancer. One hundred and forty (70%) of respondents had never encountered the term "Head & Neck Cancer". One hundred and forty six (73%) failed to identify excessive alcohol consumption as a risk factor. Less than 100 (50%) would have concern about persisting hoarseness or a prolonged oral ulcer. An urgent need exists to raise awareness of Head & Neck Cancer among the public in Ireland.

Drop weld thermal injuries to the middle ear

Drop weld injuries to the tympanic membrane and middle ear caused by hot sparks or molten slag are a rare but significant injury. Steel workers and welders who are regularly exposed to flying sparks and molten metal slag are predisposed. This type of transtympanic thermal injury occurs when the slag literally drops into the external auditory canal and burns through the tympanic membrane. A spectrum of severity of injury occurs which includes chronic tympanic membrane perforation, chronic otorrhoea, facial nerve injury and deafness. Chronic tympanic membrane perforation is the most common sequelae and is perhaps one of the most challenging of all perforations to repair The combination of direct thermal injury and foreign body reaction results in continuing or recurrent suppuration. The foreign body reaction is due to the embedding of metal slag in the promontorial mucosa. We present a case of drop weld injury to the left tympanic membrane, resulting in chronic middle ear inflammation, otorrhoea and tympanic perforation. CAT scan clearly demonstrated a metallic promontorial foreign body with localised bone erosion. We emphasise the importance of removing these foreign bodies and recommend a cartilage reinforced underlay tympanoplasty technique to repair these perforations. Transtympanic thermal trauma is a preventable occupational injury, which is best, avoided by earplugs and increased awareness.

Isolated microtia as a marker for unsuspected hemifacial microsomia

OBJECTIVE

To determine the proportion of hemifacial microsomia (HFM) in patients with unilateral or bilateral "isolated" microtia.

DESIGN

Prospective cohort clinical study.

SETTING

University-affiliated, tertiary referral clinic for patients with microtia.

PATIENTS

One hundred consecutive patients with isolated microtia.

INTERVENTIONS

All the patients underwent a clinical examination and audiologic evaluation. The OMENS classification system was used to grade the severity of craniofacial features: orbital deformity, mandibular hypoplasia, ear deformity, nerve (cranial nerve VII) involvement, and soft-tissue deficiency. Each anatomical abnormality was graded from 0 (normal) to 3 (most severe) (score range, 0-15).

MAIN OUTCOME MEASURES

The OMENS scores, percentage of patients with isolated microtia and undiagnosed HFM, and isolated microtia as an early clinical marker for HFM.

RESULTS

Forty patients (40%) with microtia were determined to have HFM (31 unilateral and 9 bilateral). Mean patient age was 9.2 years (range, 6 weeks to 41 years), with male predominance (27 males and 13 females). The OMENS scores were less than 5 in 24 patients and 6 to 10 in 16 patients. Thirty patients had cranial nerve deficits, and 37 had mandibular asymmetry. Thirty-seven patients demonstrated conductive hearing loss, and 1 had sensorineural hearing loss.

CONCLUSIONS

Isolated microtia served as an early clinical marker for asymmetrical facial growth in 40% of the patients. Isolated microtia and HFM could represent a spectrum of expression of the same developmental phenomenon.

Complete branchial cleft fistula: diagnosis and surgical management

Branchial cleft fistulae are rare congenital abnormalities that arise from the abnormal persistence of branchial apparatus remnants. A complete fistula is a tract that has an internal opening and an external opening. Second branchial cleft fistulae pass deep to second arch structures and over third arch structures, in a direction extending from the anterior border of sternocleidomastoid (SCM) muscle to the upper pole of the ipsilateral tonsil fossa. Because of this anatomical route, these long tubular structures are intimately associated with major neuro-vascular structures in the neck. Fistulae are usually clinically apparent after birth with up to 80% being diagnosed before age 5 years. There may be an obvious opening in the anterior neck between the hyoid bone and suprasternal notch. Recurrent mucoid discharge becoming purulent during acute infection or associated with upper respiratory tract infection is the usual course. Treatment is complete surgical excision of all abnormally placed epithelium, while preserving surrounding neurovascular structures, and using cosmetically acceptable incisions. Complete fistulae in adults are rare and diagnosis can be difficult. We present the clinical presentation and surgical management of a long (14 cm) second branchial cleft fistula, in a 25-year-old female. Preoperative CT and MRI scans of the neck clearly demonstrated the fistula. We recommend a "stepladder" or Mc Fee incision and intra-oral pull-through fistulectomy to allow safe and complete excision.

The use of botulinum toxin in Frey's Syndrome

Frey's Syndrome, or gustatory sweating, occurs in over 50% of patients following superficial parotidectomy. In the vast majority of cases, these symptoms are not severe enough to require surgical treatment and can be effectively treated with topical anticholinergics and antihyperhydrotics. Patients with recalcitrant Frey's Syndrome can be treated by a variety of surgical procedures. However, the potential risks and side effects of these surgical procedures often outweigh the benefits. Botulinum toxin A has recently emerged as a popular treatment option for a number of head and neck conditions. The anticholinergic effects of Botox make it particularly suitable for the treatment of Frey's Syndrome. We report our experience.

Neglected keratosis obturans causing facial nerve palsy

Keratosis obturans is characterized by the accumulation of desquamated keratinous material in the bony portion of the external auditory canal. Classically, it is reported to present with severe otalgia, conductive hearing loss and global widening of the external auditory canal. Extensive erosion of the bony meatus, with exposure of the facial nerve, has been previously reported, but no case of facial nerve palsy has as yet been published. We report the first published case, to our knowledge, of a unilateral facial nerve palsy secondary to neglected keratosis obturans.

Routine nasopharyngeal biopsy in adults presenting with isolated serous otitis media: is it justified?

Nasopharyngeal malignancy accounts for less than 2 per cent of all head and neck cancers. Serous otitis media (SOM) causing deafness is a recognized indicator of nasopharyngeal obstruction and the possibility of a nasopharyngeal malignancy must be considered in all adults. Examination under anaesthesia (EUA) and biopsy of the nasopharynx is routinely undertaken in many centres to rule out nasopharyngeal malignancy in adults with SOM. The purpose of this 10-year retrospective study was to evaluate the case records of all adult cases of SOM, including their presentation, clinical findings, management and nasopharyngeal biopsy results.

Eighty-five patients were included in the study. Fifty-nine presented with unilateral SOM and 26 with bilateral SOM. The primary presenting complaint in all cases was hearing loss. A nasopharyngeal mass was documented in 55 patients (69 per cent). Four nasopharyngeal masses were noted to have irregular or exophytic mucosa on flexible nasendoscopy. All patients underwent a EUA of the ears and a nasopharyngeal biopsy. The four patients with suspicious-looking masses were all found to have malignancies (two squamous cell carcinomas, one B-cell non-Hodgkin lymphoma and one adenocarcinoma). Three of these patients presented with unilateral SOM and one with bilateral SOM. All other patients with masses were found to have benign lymphoid hyperplasia. In total, 4.7 per cent of the adults with conductive hearing loss secondary to SOM were found to have a malignancy on nasopharyngeal biopsy.

We would advocate a high index of suspicion of a nasopharyngeal tumour in adults presenting with SOM. If a mass is found in the nasopharynx then it should be biopsied. If no mass is found then it is not necessary to biopsy; however, close follow up, with repeat fibre-optic nasendoscopy, is advised.

Pediatric Cholesteatoma: Canal Wall Window Alternative to Canal Wall Down Mastoidectomy

OBJECTIVE

A previous pilot series described a hybrid mastoidectomy technique, canal wall window (CWW), which substituted for the canal wall down (CWD) procedure and involved slitting the posterior canal wall. The current, larger series compares the results of the CWW procedure with conventional surgical techniques.

STUDY DESIGN

Retrospective analysis of 78 pediatric ears.

SETTING

Academic tertiary referral center.

PATIENTS

The mean patient age was 13.5 years.

MAIN OUTCOME MEASURE(S)

The data analyzed included ears later requiring conversion from CWW to CWD, dry/moist ear results, recidivation determined by two separate methods, and audiometric data statistically analyzed using independent-samples analysis (unpaired, two-tailed Student's t test).

RESULTS

First, of 42 CWW ear procedures, 6 (14%) later required conversion to CWD. Second, dry ear results were as follows: for CWW, 94%; for CWD, 92%; and for CWU (canal wall up), 90%. Third, recidivation determined at 1 year (standard rate) was, for CWW, 19.5%; for CWD, 0%; and for CWU, 7.7%; the at-risk calculation rate was, for CWW, 27%; for CWD, 0%; and for CWU, 8.3%. The 6-year recidivation rate for all three surgical techniques was 0%. 4). The mean preoperative-to-postoperative four-tone air-bone gap change was, for CWW, from 29.7 to 26.4 dB; for CWD, from 32.9 to 39.0 dB; and for CWU, from 21.0 to 25.2 dB (postoperative CWW to CWD, p < 0.005). A postoperative air-bone gap result of 0 to 20 dB was achieved as follows: with CWW, in 13 of 36 ears; with CWD, in 2 of 14 ears; and with CWU, in 9 of 22 ears.

CONCLUSION

Frequently, a CWW procedure can be substituted for a traditional CWD procedure. In the extended series, the CWW technique continued to provide hearing results similar to CWU rather than to CWD procedures in a young population who will bear the surgical outcome for many decades.

Partial tetrasomy of chromosome 22: genetic and surgical implications for otolaryngologists

Partial tetrasomy of chromosome 22 is a rare multiple congenital anomaly syndrome that is more commonly known as cat-eve syndrome (CES). It is caused by the duplication of a 2-million base region of chromosome 22 (22 pter --> q 11 x 2). The phenotype is extremely variable, and its clinical characteristics include a combination of craniofacial, cardiac, renal, gastrointestinal, and genito-urinary defects. We describe a rare occurrence of CES in a Brazilian family: Three siblings were affected--monozygotic twin boys and their younger brother. All 3 were born to healthy nonconsanguineous parents. On examination, all 3 were found to have strabismus, primary telecanthus, bilateral coloboma iridis, and low-set ears with posterior rotation of the pinnae. Partial tetrasomy of chromosome 22 was confirmed by fluorescent in situ hybridization. To our knowledge, this is the first report of such an occurrence in one family. We discuss the genotype and phenotype of CES, with particular reference to inheritance patterns and craniofacial defects.

Partial Tetrasomy of Chromosome 22: Genetic and Surgical Implications for Otolaryngologists

Partial tetrasomy of chromosome 22 is a rare multiple congenital anomaly syndrome that is more commonly known as cat-eye syndrome (CES). It is caused by the duplication of a 2-million base region of chromosome 22 (22 pter → q 11·2). The phenotype is extremely variable, and its clinical characteristics include a combination of craniofacial, cardiac, renal, gastrointestinal, and genitourinary defects. We describe a rare occurrence of CES in a Brazilian family. Three siblings were affected—monozygotic twin boys and their younger brother. All 3 were born to healthy nonconsanguineous parents. On examination, all 3 were found to have strabismus, primary telecanthus, bilateral coloboma iridis, and low-set ears with posterior rotation of the pinnae. Partial tetrasomy of chromosome 22 was confirmed by fluorescent in situ hybridization. To our knowledge, this is the first report of such an occurrence in one family. We discuss the genotype and phenotype of CES, with particular reference to inheritance patterns and craniofacial defects.

Clinical and genetic linkage analysis of a large Venezuelan kindred with Usher syndrome

OBJECTIVE

To undertake a comprehensive investigation into the very high incidence of congenital deafness on the Macano peninsula of Margarita Island, Venezuela.

METHODS

Numerous visits were made to the isolated island community over a 4-year-period. During these visits, it became apparent that a significant number of individuals complained of problems with hearing and vision. Socioeconomic assessments, family pedigrees and clinical histories were recorded on standard questionnaires. All individuals underwent thorough otolaryngologic and ophthalmologic examinations. Twenty milliliters of peripheral venous blood was obtained from each participant. A genome-wide linkage analysis study was performed. Polymorphic microsatellite markers were amplified by polymerase chain reaction and separated on polyacrylamide gels. An ABI 377XL sequencer was used to separate fragments and LOD scores were calculated by using published software.

RESULTS

Twenty-four families were identified, comprising 329 individuals, age range 1-80 years, including 184 children. All families were categorized in the lower two (least affluent) socioeconomic categories. A high incidence of consanguinity was detected. Fifteen individuals (11 adults, 4 children) had profound congenital sensorineural hearing loss, vestibular areflexia and retinitis pigmentosa. A maximum LOD score of 6.76 (Linkage >3.0), between markers D11s4186 and D11s911, confirmed linkage to chromosome 11q13.5. The gene myosin VIIA (MYO7A) was confirmed in the interval. Clinical and genetic findings are consistent with a diagnosis of Usher syndrome 1B for those with hearing and vision problems.

CONCLUSIONS

We report 15 Usher syndrome 1B individuals from a newly detected Latin American socio-demographic origin, with a very high prevalence of 76 per 100,000 population.

Wegener's granulomatosis masquerading as unilateral sinusitis

Wegener's Granulomatosis (WG) is a rare, multi-system disease of unknown aetiology. The disease is characterised by necrotizing granulomas and vasculitis of the upper and lower respiratory tracts and kidneys. The sinonasal region may be the first area to manifest this systemic condition. If the disease is diagnosed early and treated appropriately, involvement of the lungs and kidneys may be averted. Left untreated, the disease may prove rapidly fatal. A low threshold of clinical suspicion must be maintained. We report a case, of a middle aged patient who presented with unilateral sinusitis secondary to a large obstructive nasal mass. Anti neutrophil cytoplasmic antibody (ANCA) titres helped confirm the diagnosis of WG. Unilateral sinusitis with a nasal mass, is a very unusual presentation of WG, and emphasises the importance of a low threshold of suspicion for patients presenting with atypical sinonasal symptoms.

Critical airway compromise caused by neck haematoma

The recognition and treatment of the compromised airway needs to be quick and systematic. Airway obstruction, can rapidly progresses to anoxia irreversible cerebral damage and death, within four to five minutes. Management of the unstable airway has the highest treatment priority regardless of the presence of other medical conditions. We report the clinical course of minor anterior neck injury in two elderly patients taking oral anticoagulants. Both patients developed sudden airway obstruction, due to circumferential neck haematoma; six to eight hours post injury. The rapid neck swelling caused upper airway compression and rapid desaturation. Both patients required urgent orotracheal intubation in the emergency room. Patients with a history of blunt neck trauma may initially appear stable, then quickly decompensate and require an emergency airway.

Minor salivary glands: causing major problems

Tumours arising in the parapharyngeal space (PPS) are rare and account for approximately 0.5% of all head and neck neoplasms. These neoplastic processes represent a wide variety of both benign (80%) and malignant lesions arising from the diverse range of structures within and surrounding the PPS. The PPS is typically conceptualized as a potential neck space in the shape of an inverted cone with its base at the skull base and apex at the greater cornu of the hyoid. Because of this unique structure, lesions must often grow to a considerable size before symptoms become apparent and clinical detection is possible. A rare case of mucoepidermoid tumour of the minor salivary glands arising in the prestyloid parapharyngeal space is described. The complex anatomical and pathological considerations within this region present a substantial challenge to the head and neck surgeon in the evaluation and management of these lesions.

Blood splash and tonsillectomy: an underestimated hazard to the otolaryngologist

Mucocutaneous exposure is an important route of transmission of hepatitis viruses and HIV in healthcare workers. Few data exist in the literature on the risk of transconjunctival exposure during many surgical procedures. We investigated the use of eye protection during tonsillectomy and measured the incidence of potential eye splash. No otolaryngologist surveyed routinely used eye protection during tonsillectomy. Splash events occurred in 23 out of 103 tonsillectomies. In all cases the surgeon was unaware of the splash. Splash events were significantly more likely to occur during adult tonsillectomy (p < 0.05). We strongly advise the routine use of eye protection during tonsillectomy.

Sigmoid sinus thrombosis: an old foe revisited

Sigmoid sinus thrombosis (SST) has become increasingly uncommon. In the pre-antibiotic era this condition had a mortality rate of over 90%.1 A high index of suspicion is required to make the diagnosis. We present a rare case of sigmoid sinus thrombosis secondary to mastoiditis, which illustrates the problems of delayed diagnosis. This report highlights the importance of rapid diagnosis and early surgical intervention. We emphasis the need for scanning and otolaryngology referral in all cases of middle ear disease associated with pain or vertigo which does not resolve rapidly on appropriate antibiotic therapy.

Serious complication of tongue piercing

The case of an 18-year-old patient who developed critical upper airway compromise after central tongue piercing is presented. Otolaryngologists must be aware of the many potential complications of tongue piercing and their management.