‘High stakes’ postgraduate medical examinations should conform to current educational standards. In the UK and Ireland, national assessments in surgery are devised and managed through the examination structure of the Royal Colleges of Surgeons. Their efforts are not reported in the medical education literature. In the current paper, we aim to clarify this process.

To replace the clinical section of the Diploma of Otorhinolaryngology with an Objective, Structured, Clinical Examination, and to set the level of the assessment at one year of postgraduate training in the specialty.

After ‘blueprinting’ against the whole curriculum, an Objective, Structured, Clinical Examination comprising 25 stations was divided into six clinical stations and 19 other stations exploring written case histories, instruments, test results, written communication skills and interpretation skills. The pass mark was set using a modified borderline method and other methods, and statistical analysis of the results was performed.

The results of nine examinations between May 2004 and May 2008 are presented. The pass mark varied between 68 and 82 per cent. Internal consistency was good, with a Cronbach's α value of 0.99 for all examinations and split-half statistics varying from 0.96 to 0.99. Different standard settings gave similar pass marks.

We have developed a summative, Objective, Structured, Clinical Examination for doctors training in otorhinolaryngology, reported herein. The objectives and standards of setting a high quality assessment were met.

We report a case of benign intranodal neurilemmoma, an extremely rare tumour arising from a nerve sheath within a lymph node.

A 67-year-old woman underwent surgery for a left-sided parotid mass. Histopathological analysis revealed a tumour arising from a lymph node within the superficial lobe of the parotid gland. The tumour demonstrated histological features of an intranodal neurilemmoma.

This case represents the first report of an intranodal neurilemmoma arising within a parotid lymph node, and supports the proposal that intranodal neurilemmoma be recognised as a distinct histological entity.

Considerable controversy exists regarding the merits of elective neck dissection in patients with early stage oral cavity and oropharyngeal squamous cell carcinoma. It is highly desirable to have a method of identifying those patients who would benefit from further treatment of the neck when they are clinically node-negative. The purpose of the present study was to examine the use of sentinel lymph node biopsy in identifying occult neck disease in a cohort of patients with node-negative oral cavity and oropharyngeal squamous cell carcinoma.

We evaluated a total of 13 patients with oral cavity and oropharyngeal cancer who were clinically and radiologically node-negative.

A sentinel lymph node was found in all 13 patients, revealing metastatic disease in five patients, four of whom had one or more positive sentinel lymph nodes. There was one false negative result, in which the sentinel lymph node was negative for tumour whereas histological examination of the neck dissection specimen showed occult disease.

In view of these findings, we would recommend the use of sentinel lymph node biopsy in cases of oral cavity and oropharyngeal squamous cell carcinoma, in order to aid the differentiation of those patients whose necks are harbouring occult disease and who require further treatment.

We report the second published case of a child with a serious traumatic injury involving the fixture and abutment of their bone-anchored hearing aid.

Case reports and review of the world literature concerning unusual complications following trauma to bone-anchored hearing aids.

A nine-year-old girl with Dubowitz syndrome sustained an intrusion injury of her bone-anchored hearing aid fixture and abutment following a fall. No other injury was sustained, and there was no neurological complication. The patient underwent immediate removal of the implant and subsequently made a full recovery. Such serious and unusual complications are fortunately very rare. On review of the literature, four cases of similar complications were identified. Only one involved a traumatic injury in a child.

Provision of bone-anchored hearing aids involves many clinicians. All clinicians involved in this procedure must be aware of the need to monitor their patients carefully, and to remember that unusual and unexpected complications, although rare, do happen. The patient's need for care continues long after the surgery is complete.

The advantages of bilateral, simultaneous cochlear implantation include: the possibility to pre-empt cochlear calcification following meningitis; reduction of the intervention to only one procedure, general anaesthetic and course of clinical care (with obvious benefits for the patient); and greater cost-effectiveness. The disadvantages of such a procedure include: doubling the risk of associated complications; placing the patient on the implanted side during contralateral implantation; the possibility of vestibular alteration simultaneously in both ears; the need for precise planning of symmetrical incisions and implant sites; and longer surgery time.

The study cohort included 10 children who underwent bilateral, simultaneous cochlear implantation using the suprameatal approach.

The overall operation time, inclusive of anaesthesia, was approximately three hours in all cases. None of the children had any intra- or post-operative complications.

From a surgical perspective, bilateral, simultaneous cochlear implantation is a safe procedure. The use of a non-mastoidectomy approach is recommended.

Given its rarity, varied histological presentation and often pseudosarcomatous appearance, nodular fasciitis is frequently misdiagnosed on pre-operative, intra-operative and final analyses.

Four cases of nodular fasciitis are reviewed.

Physical and radiological findings were consistent with a parapharyngeal tumour, probably neurogenic, a level four neck mass suspicious for lymphoma; a sternoclavicular mass in a patient with a history of breast cancer suspicious for metastasis; and a cheek mass consistent with an accessory parotid tumour. Fine needle aspiration results were consistent with a neurogenic tumour in two patients and an undifferentiated malignancy in two patients. Frozen section examination most commonly included masses with spindle-type cells. The final diagnosis of nodular fasciitis was made only after permanent section and immunohistological analysis.

In a patient with nonspecific results following investigation of a head or neck mass, nodular fasciitis should be considered. Use of appropriate immunohistochemical markers will aid in the final diagnosis.

To estimate the sensitivity and specificity of computed tomography used for the detection of extranodal spread of metastatic head and neck squamous cell carcinoma, by experienced head and neck radiologists.

Participants had undergone a neck dissection for head and neck squamous cell carcinoma, together with computed tomography scanning prior to surgery (accessible for reporting). Computed tomography images were independently examined by two experienced head and neck radiologists. Nodal involvement by squamous cell carcinoma and the presence or absence of extranodal spread were recorded. Results were compared to the histological specimen. The sensitivity, specificity and positive predictive value of using computed tomography for the detection of nodal involvement and presence or absence of extranodal spread were estimated, and 95 per cent confidence intervals were calculated.

The study analysed 149 neck dissections. When using computed tomography to detect the extranodal spread of head and neck squamous cell carcinoma, radiologists A and B had sensitivities of 66 and 80 per cent, specificities of 91 and 90 per cent, and positive predictive values of 85 and 87 per cent, respectively.

The sensitivity and specificity of radiological detection of extranodal spread from head and neck squamous cell carcinoma is not well reported in the literature. Accuracy of reporting improves in the hands of experienced head and neck radiologists. This finding has clinical implications for surgical planning and adjuvant therapy requirements.

We report an extremely rare case of otitis media due to Francisella tularensis, complicated by multiple suppurative cervical lesions and a lasting conductive hearing loss.

A young woman presented with otitis media, several neck swellings and a retropharyngeal swelling. Polymerase chain reaction testing of aspirated fluid and serology confirmed the diagnosis of tularaemia. Specific antibiotic therapy initiated six weeks after the onset of initial symptoms did not resolve the disease, and open surgical drainage was necessary.

Otitis media unresponsive to conventional therapy and accompanied by unusually pronounced lymphadenopathy should prompt the clinician to consider tularaemia as a differential diagnosis, in order to initiate timely, specific therapy.

Bone-anchored hearing aids are well established, implanted devices. We present two patients who suffered mixed hearing loss and who underwent titanium implant placement in the temporal bone to enable attachment of bone-anchored hearing aids. Osseointegration is necessary for such implants to function. We report these two cases to highlight how such osseointegration may be disrupted.

Attached tissue from the explanted or removed titanium implants was examined by transmission electron microscopy and histopathological analysis.

Attached tissue from both implants showed the presence of keratinocytes at the titanium implant and living bone interface. This was confirmed by histopathological analysis. In one case, there was frank keratinocyte proliferation, which had led to osseointegration failure; in the other case, such proliferation was present but not so advanced.

These findings suggest that, in the cases reported, keratinocytes implanted between the titanium and the living bone, leading to disruption of osseointegration.

To establish the safety and effectiveness of nurse-led triage of otolaryngology out-patient referrals.

One hundred consecutive general practitioner referrals were reviewed by two consultants, two specialist registrars, two foundation year two senior house officers and two otolaryngology nurses. One of the nurses had received triage training. All referrals were triaged as ‘urgent’, ‘soon’ or ‘routine’ by each rater.

The triage-trained nurse's results demonstrated good agreement with those of the senior consultant (80 per cent). This agreement was similar to that with the other consultant (77 per cent) and the specialist registrars (79 and 82 per cent). Weighted κ statistics (correcting for chance agreement) showed that the triage-trained nurse had the second closest agreement to the senior consultant (0.66). After the actual out-patient appointments, retrospective review of the patients' case notes revealed that none had been triaged inappropriately by the trained nurse, and no urgent cases had been missed.

Triage of out-patient referrals by trained ENT nurses is safe and effective, and is an acceptable alternative to traditional consultant vetting of referrals.

A 29-year-old man presented with sudden onset of severe pain in his throat, difficulty breathing and a hoarse voice, following an episode of vomiting.

Initial laboratory tests were normal. The patient underwent fibre-optic nasendoscopy, which demonstrated a haematoma in the piriform fossa. Lateral neck radiography and subsequent computed tomography scanning confirmed a 2 cm, loculated, gas-containing collection at the level of the vallecula in the right posterolateral wall, extending to the false vocal folds and communicating between the right parapharyngeal space and the right carotid sheath. Water-soluble contrast swallow confirmed the diagnosis.

Contained oesophageal perforation.

Conservative treatment was adopted involving nil orally, intravenous antibiotics and nasogastric feeding. The patient made an uneventful recovery.

Ear, nose and throat emergency clinic services vary greatly between trusts. Their common aim is to enable acute conditions to be seen quickly and effectively within an optimum environment. There is however no ‘gold standard’ for service.

To identify an efficient model of service, and to determine whether introduction of a referral and appointment based system improves patient waiting times and appropriateness of referrals.

A prospective audit, comprising: an initial survey to appraise the existing service; telephone surveys of eight trusts in the West Midlands to determine variability of ENT emergency clinic services and to identify components of an effective service; and re-audit following implementation of a verbal referral and appointment based service.

The new service significantly reduced patient waiting times, from 70 minutes to 35 minutes (t = 6.776; p < 0.01), with an associated reduction in the variability of waiting times. Inappropriate referrals were reduced from 7 to 2 per cent. These results were achieved when a 72 per cent referrer compliance with the service was observed.

A verbal referral and appointment based system improves patient waiting times and appropriateness of referrals. Maintenance of high referrer compliance with such a system should be considered, and a tool for monitoring referring practitioners is suggested. This clinic construct model is offered as an example in order to aid delivery of an effective ENT emergency service in departments with similar patient demand and staff resources.

To investigate whether the possible pressure produced by a haematoma in the neck would be sufficient to directly compress the trachea to the point of airway obstruction.

In vitro study.

Varying pressures were applied over the second and third cartilaginous rings of 10 pig tracheas in vitro and the anterior–posterior compression was measured.

At pressures of 257 mmHg, equivalent to the maximum possible pressure in the neck (i.e. systolic blood pressure), there was an average compression of 20.8 per cent of the original anterior–posterior tracheal diameter.

This study suggests that the pressures in haematomas observed after neck surgery would not be sufficient to cause airway obstruction due to direct pressure on the trachea. Therefore, the most likely cause of airway obstruction would be supraglottic oedema secondary to venous obstruction.

Passive smoking in the paediatric age group is associated with an increased frequency of a number of childhood respiratory disorders. However, its effect on ciliary regeneration after functional endoscopic sinus surgery for chronic sinusitis has not previously been reported.

We conducted a prospective, nonrandomised cohort study on 38 paediatric patients with chronic sinusitis. We compared two patient groups – passive smokers and those not subjected to passive smoking – as regards ciliary regeneration after functional endoscopic sinus surgery, using objective methodology.

We found passive smoking to have a negative impact on sinus cilia regeneration following functional endoscopic sinus surgery.

To investigate the association of two functional single nucleotide polymorphisms in the promoter region of the interleukin-18 gene, at positions −607 and −137, with head and neck squamous cell carcinoma.

Genomic deoxyribonucleic acid was extracted, by the salting-out method, from peripheral blood leukocytes. Single nucleotide polymorphisms of the interleukin-18 gene at positions −607 (cytosine/adenine) and −137 (guanine/cytosine) were analysed by sequence-specific polymerase chain reaction.

One hundred and eleven patients (86 men and 25 women; mean age 56.7±13.7 years) and 212 regional controls (165 men and 47 women; mean age 53.3±12.2 years) were studied. Control subjects comprised healthy volunteers or cancer-free individuals presenting with otolaryngological disease. The diagnosis of squamous cell carcinoma was confirmed histopathologically. Various clinical parameters were collected at diagnosis, including tumour site, tumour size, lymph node involvement, distant metastasis and stage.

There was no significant association between the allele, genotype or haplotype frequencies of the two single nucleotide polymorphisms of the interleukin-18 promoter and the head and neck squamous cell carcinoma susceptibility or clinical parameters at diagnosis.

Interleukin-18 polymorphisms at positions −607 and −137 did not confer susceptibility to head and neck squamous cell carcinoma in southern Iranian patients.

The process of embedding tissue in paraffin degrades many important molecules involved in respiratory epithelial remodelling. We therefore examined alternative methods.

Inferior turbinate and nasal polyp biopsies were either placed in formalin or immediately snap-frozen in the operating theatre. Novel protocols for staining remodelling markers were compared with current methods.

Our method, using a mixture of three lectins, stained a significantly greater proportion of samples, compared with using Ulex europeaus lectin alone (84 vs 62 per cent; p < 0.005). Comparison of different proliferation markers showed that Ki67 was more suitable than proliferating cell nuclear antigen for frozen sections.

This study indicates that our robust, repeatable methods for examining whole mounts and for staining capillaries, cell proliferation and nuclei on the same section of nasal mucosa are superior to current methods. The use of fresh tissue that has not been paraffin-embedded would allow a greater suite of epitopes to be examined in the future.

To determine whether ultrasound-guided core needle biopsy is a safe and reliable investigation in cases of parotid swelling in which fine needle aspiration cytology has failed to give a definitive diagnosis.

Analysis of 66 ultrasound-guided core biopsy specimens of the parotid gland (the largest series reported thus far) sample number refers to histological samples throughout the paper.

All the 184 cases of parotid surgery with a histological diagnosis were included.

The sensitivity, positive predictive value and diagnostic accuracy of fine needle aspiration cytology and ultrasound-guided core needle biopsy, as compared with the final histological analysis.

Of a total of 184 patients, 89.1 per cent (164/184) had benign parotid lesions excised. The sensitivity, positive predictive value and diagnostic accuracy of fine needle aspiration cytology for benign lesions were 76.2, 84.2 and 87.5 per cent, respectively, and those of ultrasound-guided core needle biopsy were 91.7, 98.2 and 96.4 per cent, respectively. Twenty of 184 patients (10.9 per cent) had malignant lesions. The sensitivity, positive predictive value and diagnostic accuracy of fine needle aspiration cytology for detection of malignant lesions were 60, 75 and 75 per cent, respectively, while those of ultrasound-guided core biopsy were 89, 100 and 100 per cent, respectively. Non-diagnostic rates were 25.8 per cent for fine needle aspiration cytology and 4.5 per cent for ultrasound-guided core biopsy. Only one case of complications (a sub-clinical haematoma) occurred in the ultrasound-guided core biopsy group.

We propose ultrasound-guided core needle biopsy as a very safe and effective tool in cases of parotid swelling in which fine needle aspiration cytology has failed to give a definitive diagnosis.

To report the first case of mandibular branch haemangioma of the trigeminal nerve causing erosion of the petrous carotid canal. The radiological and histological findings in this case are reviewed.

A 60-year-old woman presented with severe, right-sided facial pain and paraesthesia. There were no associated symptoms of facial weakness or diplopia. A magnetic resonance imaging scan with gadolinium enhancement was performed. This showed a lesion slightly compressing the right Meckel's cave and eroding the right petrous carotid canal, occupying the foramen ovale and extending to the pterygoid muscle. The lesion was removed via a subtemporal approach.

Haemangiomas are usually found on the skin and in other soft tissues. However, this rare tumour should also be considered in the differential diagnosis of lesions occupying Meckel's cave and the foramen ovale.