Extra-nasopharyngeal angiofibroma is a rare but distinct clinical entity, different from juvenile angiofibroma.

This clinical record elucidates the only case of extra-nasopharyngeal angiofibroma arising from the septum in a female child, who presented with epistaxis.

The histopathological diagnosis was confirmed by immunohistochemistry, and the case was managed surgically with no recurrence.

In a female paediatric patient presenting with epistaxis, extra-nasopharyngeal angiofibroma (of the inferior turbinate) is a rare albeit important differential diagnosis, as it challenges the hormonal theory of angiofibroma aetiopathogenesis.

Gorham–Stout disease of the skull is a very rare entity. It presents with gradual bone resorption, and proliferation of lymphoid and vascular channels within the bony matrix. This is often a diagnosis of exclusion confirmed with serial imaging and based on radiological evidence.

A case of Gorham–Stout disease of the temporal bone involving the temporomandibular joint, and presenting with sensorineural hearing loss and recurrent temporomandibular joint dislocation, is reported. The findings are presented and the literature on this condition is reviewed.

ENT and maxillofacial surgeons should be aware of this extremely rare cause of temporomandibular joint dislocation and ear symptoms. Imaging comprising computed tomography and magnetic resonance imaging is crucial to achieving a diagnosis, which may only become evident after repeated imaging follow up. Symptomatic treatment is advised, with the option of anti-osteoclastic medication and radiotherapy indicated for advanced cases. Surgery is only recommended for complications including involvement of neurovascular structures.

Parapharyngeal space biopsy is an important investigation in the management of parapharyngeal space tumours. These tumours are relatively rare and the surgeon is often faced with a wide range of differential diagnoses. There are several ways to access the parapharyngeal space, with varying degrees of associated morbidity.

This paper describes a seldom used, but a simple and safe, image-guided endoscopic approach to parapharyngeal space biopsy that enables tissue to be obtained transnasally. The procedure is conducted under general anaesthesia using computed tomography image guidance via the LandmarX system, with transnasal access to the parapharyngeal space achieved using a sampling needle.

This procedure is relatively simple, safe and reproducible. It is a less invasive approach to parapharyngeal space biopsy, and one which has been successfully used by the senior author for years without any significant morbidity.

Transnasal image-guided endoscopic aspiration or biopsy of the parapharyngeal space is a novel technique that has not been previously described.

Oesophageal disorders and osteonecrosis of the jaw are recognised complications of the commonly prescribed medication bisphosphonate. Despite these diagnoses being seen comparatively frequently within the ENT clinic, osteonecrosis of the external ear is a less well reported complication.

The current literature is reviewed and our experience with six cases of bisphosphonate-related ear canal osteonecrosis is presented.

Six cases were identified as suffering from ear canal osteonecrosis as a result of bisphosphonate treatment. One of our cases suffered bilateral ear canal osteonecrosis after only 20 months of oral alendronic acid treatment. Management ranged from bisphosphonate cessation and topical treatment, to surgical debridement in the operating theatre.

Bisphosphonate-related ear canal osteonecrosis is undoubtedly under-diagnosed. For such a commonly prescribed medication, the risks and side effects of bisphosphonate should be better known and long-term treatment should be avoided if possible.

Dislocation of the cochlear implant magnet is an uncommon but recognised complication of magnetic resonance imaging in a patient with a cochlear implant.

This paper reports a case of cochlear implant magnet dislocation despite head bandaging. The patient subsequently underwent endoscopic repositioning of the magnet under general anaesthesia. The cochlear implant system was tested intra-operatively and confirmed to be functioning. The patient was well at follow up and the small wound healed well with no complications.

This report presents the endoscopic technique as a viable minimally invasive surgical approach to address cochlear implant magnet dislocation.

In order to improve a large posterior glottal gap and/or aspiration, injections of augmentation substances should not only be administered at the mid-membranous vocal fold in the thyroarytenoid muscle, but also at the cartilaginous portion of the vocal fold to make adduction arytenopexy possible.

Ten adult human larynges were investigated using the whole-organ serial section technique.

Vertical thickness of the posterior aspect of the thyroarytenoid muscle was relatively thin (3.4 ± 0.4 mm), especially in females (3.2 ± 0.3 mm). Consequently, care should be taken to ensure the correct depth of needle placement. If the needle is placed too deep, augmentation substances are injected into the lateral cricoarytenoid muscle, located beneath the thyroarytenoid muscle, or into the paraglottic space, located inferolateral to the thyroarytenoid muscle.

The injection location and the amount of injected material should be modified based on the pathological conditions of the voice disorder and aspiration.

Juvenile nasopharyngeal angiofibroma often attaches firmly to the adjoining bony region around the sphenopalatine foramina–sphenopalatine fossa–pterygomaxillary fissure. This can result in hourglass-shaped constriction and predispose to incomplete resection (residual disease) with a transpalatal approach. This paper describes attempts to address this ‘inaccessible’ area with a novel instrument, used since 2012.

Measurements of the sphenopalatine foramen, nasal septum, posterior nasopharyngeal wall and hard palate were undertaken in 20 skulls and 10 computed tomography scans (lateral extension). A device was designed (in terms of angulation and length) following several trials with malleable wire. A search of patents was also undertaken. Recurrence rates were compared in cases of device use and non-use.

The novelty of the sphenopalatine fossa dissector was established and the device was patented. This device has significantly improved our 17.59 per cent recurrence rate of the past 4 decades; of 63 cases over 3 years, there were only 3 recurrences and 2 residual disease cases. Findings of our previous studies with or without the device are compared.

Existing evidence supports the incorporation of this inexpensive instrument in the armamentarium for resecting lateral extension of juvenile nasopharyngeal angiofibroma during a transpalatal approach.

Unilateral total facial palsy is a debilitating condition that can affect an individual's physical, social and emotional wellbeing. When this occurs bilaterally, the severity of impact is extreme, with significant cosmetic disfigurement and functional morbidity. A variety of facial reanimation techniques have been used for unilateral facial weakness of varying House–Brackmann grades, and these are also applicable in bilateral cases. In bilateral cases, it is difficult to gauge successful improvement in comparison to the contralateral side, which also is afflicted.

This paper presents our experience with a bilateral facial paralysis patient who had a complex otological history. The patient, who presented with bilateral debilitating grade VI facial palsy, achieved a good result from bilateral facial reanimation with sequential hypoglossal–facial anastomosis. This is considered a reasonable option in cases of bilateral facial paralysis.

To evaluate the presence of endolymphatic hydrops in patients with immune-mediated inner-ear disease.

The presence of endolymphatic hydrops was prospectively evaluated in 17 patients clinically diagnosed with secondary (n = 5) or primary (n = 12) immune-mediated inner-ear disease, who attended the ENT department of a tertiary care centre for evaluation or treatment over the previous year. All patients underwent magnetic resonance imaging of the temporal bone.

Intratympanic gadolinium three-dimensional magnetic resonance imaging diagnosed hydrops in 11 of 12 patients with primary immune-mediated inner-ear disease (92 per cent). Of these, seven patients (64 per cent) presented only cochlear (n = 5) or predominantly cochlear (n = 2) hydrops. A positive magnetic resonance imaging result was observed in only one of five patients with secondary immune-mediated inner-ear disease (20 per cent).

This study confirms the presence of endolymphatic hydrops in immune-mediated inner-ear disease patients. The virtual absence of hydrops in patients with secondary immune-mediated inner-ear disease is remarkable, although firm conclusions cannot be drawn; this should be explored in a multicentre study with a larger sample of patients. A different immune reaction without development of endolymphatic hydrops should not be ruled out in secondary immune-mediated inner-ear disease patients.

This paper presents a rare case of oculostapedial synkinesis.

After partial resolution of an idiopathic facial palsy, a male patient presented with persistent distortion of hearing when blinking and closing his eye. Audiometry findings were unremarkable, and cross-sectional imaging of the facial nerve revealed no abnormalities apart from an incidental contralateral meningioma. Initial conservative management, with referral to a specialist physiotherapist, failed to resolve the symptoms. The patient subsequently opted for surgical intervention, and underwent a transmeatal tympanotomy and transection of the stapedial tendon. Following this, he had complete resolution of symptoms.

Oculostapedial synkinesis is a rare complication of facial palsy, but is recognised in the literature. Given its unusual presentation, it can be overlooked, especially by more junior team members. This case highlights the need to pay careful attention to patients' symptoms and listen out for the description of hearing distortion on facial movement.

There is currently no general consensus on patulous Eustachian tube management. Injection of autologous fat, cartilage or hydroxylapatite has been described for Eustachian tube occlusion, with promising results. However, complete resolution of symptoms is not achieved in all cases. This could be connected to the amount of material injected into the surroundings of the Eustachian tube, as this greatly differs among existing studies. Identifying the appropriate volume of injected material could be challenging because anatomical conditions vary among patients, and there is always a risk of chronic Eustachian tube obstruction and its related complications when too much long-standing material is injected.

A case is presented wherein saline was injected under local anaesthesia to determine the volume required and to predict the success of patulous Eustachian tube augmentation with long-standing material.

This approach could allow more personalised treatment and help identify patients likely to benefit from the procedure.

Benign paroxysmal positional vertigo is a common inner-ear pathology, characterised by episodic vertigo lasting for a few seconds that is associated with sudden change in the head position. Benign paroxysmal positional vertigo is treated with canalolith repositioning manoeuvres. Intractable vertigo describes a small group of patients who either do not improve with canalolith repositioning manoeuvres (persistent cases) or who relapse after improvement of initial symptoms (recurrent cases). These cases are difficult to treat and may have to be treated surgically.

This paper reports two cases of intractable posterior canal benign paroxysmal positional vertigo that were treated with intratympanic dexamethasone injections on an interval basis.

Both patients showed good control of their vertiginous symptoms, with negative Dix–Hallpike test findings following the intervention.

The findings support an underlying inflammatory pathology in intractable benign paroxysmal positional vertigo; intratympanic steroids should be considered as an intermediate option before proceeding to a definitive surgical intervention.