Deafness in Vogt-Koyanagi-Harada syndrome.

Sudden onset sensorineural hearing loss is a well recognized entity frequently encountered in otolaryngological practice. However, the combination of such deafness as part of a wider systemic disorder is fortunately rare. Almost 100 years after the syndrome was classified, we describe a case of Vogt-Koyanagi-Harada syndrome occurring unusually in a Caucasian woman and characterized by sudden hearing loss. A brief review of this rare condition is presented.

Malignant transformation in a laryngeal hemangioma.

Laryngeal angiosarcoma is uncommon, with only 19 previously reported cases. Malignant transformation in nonirradiated hemangiomas is extremely rare, with only five equivocal cases reported, all of which occurred in the skin. We report the first documented case of malignant transformation in a laryngeal hemangioma, and review the literature.

Investigation of the physiological basis of summating potential changes in endolymphatic hydrops.

An increase in the ratio of the summating potential to the action potential components of the electrocochleogram is known to be a feature of endolymphatic hydrops. We investigated the value of the SP/AP ratio in response to condensation and rarefaction click stimuli delivered separately. In patients with electrophysiological evidence of endolymphatic hydrops there was found to be a significantly greater SP/AP ratio to condensation clicks than rarefaction clicks. This finding supports the hypothesis that the increased SP/AP ratio in hydrops is due to mechanical asymmetry of the basilar membrane.

Temporal bone laboratory training for stapedectomy.

Practice in the Temporal Bone laboratory is a fundamental part of Otological training. Performing a stapedectomy on a normal temporal bone is handicapped by the mobility of the footplate. We describe a simple method of producing stapes footplate fixation in a normal temporal bone so that the operative conditions found in otosclerosis are more closely simulated.

Respiratory problems in acromegaly.

Death from respiratory causes in acromegaly is three times more common than in the general population and is most often the result of upper airways obstruction, although less commonly pulmonary dysfunction and disturbance of the central nervous system may occur. These factors may be found alone or in combination. Despite several reports of laryngeal involvement, upper airway obstruction in acromegaly is usually regarded as being due to macroglossia and pharyngeal soft tissue hypertrophy. We present four cases of acromegaly in which tracheostomy was required for laryngeal obstruction, with a review of the literature concerning the nature of respiratory problems in acromegaly.

Endoscopic dacrocystorhinostomy: long-term results and evolution of surgical technique.

This study evaluated the long-term results of endoscopic dacrocystorhinostomy (DCR) performed as a day-case procedure under local anaesthesia. It assessed the patient satisfaction with the procedure by retrospective review and a questionnaire survey. Seventy patients were referred for endoscopic DCR to the senior author between 1997 and 2000. A success rate of 92 per cent was achieved at three months and it was possible to perform 85 per cent of cases under local anaesthetic; 91 per cent were discharged on the same day. Long-term follow up by postal survey revealed that the watering eye had improved following surgery in 83 per cent (follow up range = eight to 66 months; mean = 28.6 months). Eighty-eight per cent were satisfied with the tolerability of the procedure under local anaesthesia. The authors describe changes in technique, which evolved with their experience of the procedure. Endoscopic dacrocystorhinostomy can be performed safely and successfully as a day-case procedure under local anaesthesia with excellent results and with great satisfaction to the patients.

Congenital cholesteatoma.

We present a British series of eleven patients with primary cholesteatoma, including one patient with bilateral disease. Eight children presented with a history of hearing loss, while one child had had recurrent otitis media and another had had earache. Operative findings were: in five ears, cholesteatoma confined to the antero-superior segment with intact ossicles, in a further four, cholesteatomas extending throughout the mesotympanum with ossicular erosion in one, and in two ears posterior disease throughout the middle ear and mastoid, which had eroded the ossicles in both cases. The five cases of antero-superior cholesteatoma lend most support to Michaels' concept of epidermoid formation as a possible source of congenital cholesteatoma. With a greater awareness of the problem and careful examination of the antero-superior quadrant of the tympanic membrane, earlier diagnosis may be possible enabling removal of small intact cholesteatoma sacs and preserving the structures of the middle ear and therefore the hearing. A screening programme for infants included as part of their routine examination which would be undertaken by examiners who are trained to be more aware of the problem and skilled at otoscopy, would help in the earlier detection of such cases as is shown by reports from the U.S.A.

A unique parotid adenocarcinoma.

A large number of different types of benign and malignant tumours of the salivary glands are recognized, and rare and unusual variants arise from time to time that can be difficult to interpret. We report an apparently unique parotid neoplasm that does not fit any of the currently recognized diagnostic groups and can best be termed lymphadenocarcinoma. Clinical and pathological features are described, and its possible relationship to recognized tumour types is examined.

Haemangioma of the frontal sinus.

A 71-year-old lady underwent successful excision of a haemangioma of the frontal sinus, via an osteoplastic flap approach. Haemangioma of the paranasal sinuses is an extreme rarity. A case is presented and the literature reviewed.

Management of globus pharyngeus: review of 699 cases.

The principal reason for performing investigations in patients with globus pharyngeus is to detect a pharyngeal or upper oesophageal malignancy presenting this way. There is uncertainty regarding both the necessity for investigation in globus patients and the first line investigation of choice in the screening of such patients. The authors therefore undertook a retrospective study of 699 patients who presented with globus sensation. Of these, 451 patients (64.5 per cent) had a typical history and in these patients, outpatient examination, including fibre-optic nasendoscopy was able to detect all pathologies, except one insignificant pharyngeal pouch, which required no intervention and one patient with a distal peptic stricture. In patients with atypical symptoms the combination of fibre-optic nasendoscopy and barium swallow identified all pathologies (five aerodigestive tract malignancies) except one distal peptic stricture. The authors concluded that if out-patient examination is adequate, no further investigation of typical globus symptoms is required. Such a policy would produce significant savings for both out-patient and radiology services.

Atypical incus necrosis: a case report and literature review.

OBJECTIVE: We report an atypical case of ossicular necrosis affecting the incus, in the absence of any history of chronic serous otitis media. We also discuss the current theories of incus necrosis. CASE REPORT: A male patient presented with a history of right unilateral hearing loss and tinnitus. Audiometry confirmed right conductive deafness; tympanometry was normal bilaterally. He underwent a right exploratory tympanotomy, which revealed atypical erosion of the proximal long process of the incus. Middle-ear examination was otherwise normal, with a mobile stapes footplate. The redundant long process of the incus was excised and a partial ossicular replacement prosthesis was inserted, resulting in improved hearing. CONCLUSION: Ossicular pathologies most commonly affect the incus. The commonest defect is an absent lenticular and distal long process of the incus, which is most commonly associated with chronic otitis media. This is the first reported case of ossicular necrosis, particularly of the proximal long process of the incus, in the absence of chronic middle-ear pathology.

Use of intranasal corticosteroids in sinonasal infection and after surgery.

The use of intranasal steroids by otolaryngologists in the treatment of patients with infective rhinosinusitis and after endonasal surgery, particularly endoscopic sinus surgery, is unlicensed, as stated in the British National Formulary and in the manufacturers' leaflets supplied with nasal steroid medications. However, despite this, nasal steroids continue to be prescribed in these circumstances. Debate continues as to the exact role of intranasal steroids in sinonasal infection and after sinonasal surgery and whether their use in these circumstances should still be unlicensed. This article reviews the current medical literature regarding this topic and aims to clarify whether intranasal steroid usage in these circumstances should be recommended.

Is aspiration of middle ear effusions prior to ventilation tube insertion really necessary?

A prospective double blind randomized trial of 55 children undergoing myringotomy and insertion of ventilation tubes for bilateral middle ear effusions was undertaken. The aim of the study was to assess the need for clearance of the middle ear by aspiration prior to the insertion of ventilation tubes. The day before surgery the children were assessed by clinical examination, pure tone audiometry and impedance audiometry. At the time of surgery each child underwent bilateral myringotomy, with aspiration of the right or left ear only on a randomly allocated basis. Standard ventilation tubes were then inserted. Postoperative evaluation up to three months following surgery showed no significant differences between the aspirated and the non-aspirated middle ears. We conclude that routine evacuation of the middle ear prior to ventilation tube insertion is not necessary.

Audiovestibular complications of non-otological surgery.

Post-operative dizziness or imbalance is often regarded as 'trivial' and self-limiting and vaguely ascribed to the drugs used in anaesthesia or to haemodynamic changes. While hearing loss after anaesthesia has been documented in several studies, very little attention has been paid to a possible vestibular cause for post-operative dizziness. Twelve patients with post-operative vestibular disorders, with or without concomitant hearing loss, and one patient with tinnitus are described. As effective management for vestibular dysfunction exists, the importance of identifying this potential cause of dizziness is emphasized.

Button batteries in the ear, nose and cervical esophagus: a destructive foreign body.

Button batteries spontaneously leak alkaline electrolyte solution on exposure to moisture, causing liquefaction necrosis of adjacent tissue. We describe two cases in which a button battery in the external auditory meatus caused skin, bone and tympanic membrane necrosis. Review of the world literature on button batteries acting as foreign bodies reveals lower motor neurone facial nerve palsy, nasal septal perforation and fatal esophago-aortic fistula as among the ENT complications. Batteries lodged in these sites must be removed as a matter of the utmost urgency.

Cholesterol granuloma of the maxillary antrum.

A case of cholesterol granuloma of the maxillary antrum is presented, the eighth reported case in the ENT literature. It is postulated that a maxillary antral cholesterol granuloma could be associated with obstruction of the antral ostia, hemorrhage into polypoidal mucosal disease or that an antral cyst may have developed a cholesterol granuloma in its walls as a result of cholesterol precipitation. A review of the literature on cholesterol granuloma suggests that it is a condition which arises in a closed space with poor ventilation or drainage, with long-standing inflammation with effusion or hemorrhage contributing to the formation of free cholesterol crystals derived from tissue or blood breakdown products. The foreign body granuloma produced in this way is then self-perpetuating and requires complete removal for cure rather than a simple drainage procedure.