To propose an alternative site of thyroid drain placement.

During thyroid surgery, post-operative drains are often placed. It is common practice to bring out the drain lateral to the wound, often creating an additional, unsightly scar.

We have found excellent cosmesis is achieved by bringing out the drain in the midline in a sub-mental skin crease, with the scar hidden in the chin shadow. In our experience, such drain placement is a safe, straightforward method with an excellent cosmetic result.

Branchial cleft anomalies are well described, with the second arch anomaly being the commonest. Following surgical excision, recurrence occurs in 2 to 22 per cent of cases, and is believed to be due largely to incomplete resection. This report aims to describe a simple surgical technique for treatment of second branchial cleft sinus in the older paediatric age group and adults.

An 11-year-old girl underwent surgical excision of a second branchial sinus. Prior to surgery, she was assessed by means of an imaging sonogram, and by direct methylene blue dye injection into the sinus on the operating table, followed by insertion of a metallic probe. Dissection was of the ‘step ladder’ incision type, but the incision was completed via an oropharyngeal approach. Histological examination of the lesion after excision established the diagnosis. No recurrence had been observed at the time of writing.

Although they are congenital lesions, second branchial cleft abnormalities usually present in the older paediatric age group or even in adulthood. In the case reported, a simple combined approach ensured completeness of resection.

Endoscopic digital photography usually involves expensive and often cumbersome equipment.

This study aimed to construct a low cost adaptor with which to connect a budget-priced digital camera to a nasal endoscope, in order to enable inexpensive, good quality otology photography.

A method of making an adaptor from a simple plastic bottle top is described, and the photographic technique is outlined.

The adaptor fitted well with commonly used endoscopes, and excellent results were obtained.

High quality digital endoscopic photographs can be obtained using a low cost compact digital camera fitted with a simple adaptor made from a plastic bottle top. Such a method would make digital photography via a rigid endoscope easily affordable worldwide.

Epistaxis is a common condition presenting to emergency and ENT clinics. Most epistaxis bleeding originates from Little's area of the nasal septum. Some cases of refractory epistaxis cannot be resolved with packing or electrocoagulation.

The suturing technique applied is widely used in surgery. When faced with pulsatile, recurrent bleeding from Little's area of the nasal septum, all rhinologists should possess the skills to be able to suture the bleeding site, especially after failure of local cautery or packing.

The authors have successfully treated four difficult cases of nasal bleeding from Little's area by suturing.

This technique could eliminate the discomfort and complications of nasal packing. To the best of our knowledge, this report probably represents the first published case series of suturing of Little's area to treat recurrent nasal bleeding. More cases need to be treated in this way to enable further evaluation of the technique.

To present the successful treatment of sensorineural hearing loss secondary to Langerhans' cell histiocytosis with low-dose radiotherapy, and also the disparity between radiological resolution of Langerhans' cell histiocytosis lesions and lack of sensorineural hearing loss improvement, accompanied by a review of the literature on otolaryngological manifestations and management of Langerhans' cell histiocytosis.

Langerhans' cell histiocytosis is a multisystem disease which frequently causes osseous lesions in the temporal bones. Hearing loss is usually conductive but may be sensorineural with lesions of the petrous temporal bone. We present a case of sensorineural hearing loss secondary to Langerhans' cell histiocytosis affecting the labyrinth and internal auditory meatus, which resolved following radiotherapy. Contralateral sensorineural hearing loss in the same patient, previously treated with chemotherapy, did not resolve despite radiological resolution of the temporal bone lesions.

We suggest that timely radiotherapy for treatment of sensorineural hearing loss secondary to Langerhans' cell histiocytosis is an appropriate treatment option.

We report an extremely rare variant of first branchial cleft anomaly.

A 15-year-old girl presented with a history of recurrent mucopurulent discharge from an opening in the left infra-auricular region, since birth. Computed tomography fistulography showed a tortuous tract measuring approximately 4.61 cm, extending anteroinferiorly and medially from the external inframeatal opening to the lateral nasopharyngeal wall (anterior to the fossa of Rosenmuller). The tract was connected to the deep lobe of the parotid gland and lay 0.67 cm anterior to the carotid artery and posterior to the medial pterygoid muscle.

This was an extremely rare variant of first branchial cleft fistula. To the best of our knowledge, this is the first case of its type to be reported. Computed tomography fistulography is the imaging modality of choice for the diagnosis of branchial cleft fistula, and will also assist surgical planning.

The use of nasal creams and ointments in the conservative management of anterior epistaxis is well documented and supported. This study set out to obtain a national opinion, in order to establish current practice.

A survey of all Scotland-based otolaryngology clinicians was conducted. Participants were asked which topical treatment they used in their practice, how often and for how long they advocated its use, and how they advised their patients to apply it.

The overall response rate was 91 per cent. We discuss and compare the varying responses for the questions posed, and discuss the possible reasons for these in greater detail.

This study demonstrates a high degree of variation in this practice, arising from a lack of concrete evidence and influenced by anecdotal experience and personal preferences. Definitive comparative studies are required if a ‘gold standard’ topical approach for the management of anterior epistaxis is to emerge.

We report an extremely rare case of a large solitary fibroma of the paranasal sinus, which we treated by sinonasal endoscopic surgery. We describe its clinical and histopathological features, and we report the endoscopic technique used to deal with such a large sinonasal mass (penetrating the pterygomaxillary and infratemporal fossae); we also offer a brief survey of the literature.

A woman presented with an approximately one-year history of nasal obstruction. Nasal endoscopy revealed an irregularly shaped, friable, reddish mass that occupied the whole of the right nasal fossa. Magnetic resonance imaging of the paranasal sinuses revealed a large mass that occupied the anterior and posterior ethmoids and the maxillary and sphenoid sinuses, displacing the septum and penetrating the pterygomaxillary fossa, having destroyed the lateral wall of the right nasal fossa. The tumour was resected by means of sinonasal endoscopic surgery; an endoscopic medial maxillectomy with extension to the pterygomaxillary and infratemporal regions was performed. Histological analysis confirmed the diagnosis of solitary fibrous tumour. During follow up, we performed regular nasal endoscopies, as well as computed tomography scans one and six months post-operatively.

Endoscopic techniques are currently the approach of choice for the treatment of such tumours of the sinonasal cavity and pterygomaxillary and infratemporal regions. The size of the lesion did not contraindicate endoscopic sinonasal surgery as a curative treatment.

We present a rare case of perilymphatic fistula which occurred due to bony erosion by a tympanostomy tube that had migrated into and become interred in the middle-ear space.

We present a case report and a literature review concerning migration of tympanostomy tubes into the middle ear as a complication of tubes insertion.

Medial migration of tympanostomy tubes into the middle-ear space is a rare complication of tympanostomy tubes insertion. To our knowledge, this is the first report of perilymphatic fistula caused by a tympanostomy tube which had migrated into the middle ear. This case highlights the need for early removal of tympanostomy tubes which migrate into the middle ear.

To report a new, alternative treatment for nasal papillomata in human immunodeficiency virus positive patients with multiple recurrences after surgical removal.

A human immunodeficiency virus positive patient presented with multiple, recurrent nasal papillomata which developed after repeated surgical removal procedures. In this patient, complete and persistent resolution of the lesions was achieved after topical treatment with imiquimod cream.

Imiquimod is a class of non-nucleoside imidazoquinolinamines which promotes local cytokine release from antigen-presenting cells inducing a T-h1 dominant cell-mediated response against virus-infected cells. Topical imiquimod 5 per cent cream, applied for four to 16 weeks, may offer some benefit in the management of recurrent nasal papillomata in human immunodeficiency virus positive patients. Such treatment may be preferable to surgery or destructive therapeutic options when patients are unwilling or are poor surgical candidates, and also avoids potential surgical sequelae such as scar formation and stenosis.

In order to improve the outcome and to reduce the post-operative care burden following the anterior cricoid split procedure, we modified the procedure to involve splitting only the cricoid cartilage, not the mucosa deep to the cartilage. In addition, we transposed the cricoid cartilage segment after division of the cricoid ring in the midline.

We present the use of our modification in a 19-month-old boy with early-stage subglottic stenosis.

The technique was performed in one surgical field, and the graft material obtained had the same thickness as the cricoid cartilage. Because there was no intraluminal break, this procedure allowed the patient to avoid the complications of prolonged stenting, and resulted in more rapid extubation.

The anterior cricoid split procedure with transposition of the cricoid cartilage segment may be a useful treatment option for early-stage subglottic stenosis, with improved outcomes and a reduced post-operative care burden.

Magnetic resonance imaging is a routine investigation in cases of asymmetric sensorineural hearing loss, but it is not routinely used to investigate bilateral sensorineural hearing loss.

This case report illustrates the benefits of magnetic resonance image scanning in the latter patient group.

A 53-year-old man with rapidly progressive, symmetrical, bilateral, sensorineural hearing loss was found also to have anosmia, imbalance and incoordination. Magnetic resonance image scanning demonstrated leptomeningeal haemosiderosis. Progressive, bilateral, sensorineural hearing loss is the most common presentation of this condition and magnetic resonance imaging is the diagnostic investigation of choice.

There are potential treatments for leptomeningeal haemosiderosis which prevent further irreversible damage, if a bleeding source can be found. Hearing loss may be due to cochlear or retrocochlear pathology. Cochlear implantation may be indicated.

We report two cases in which dysphagia and aspiration, caused by anterior cervical osteophytes, were so severe that surgical resection was performed.

Case reports and a review of the world literature concerning dysphagia caused by anterior cervical osteophytes, in regard to pathogenesis, diagnosis and treatment.

Two patients, aged 71 and 70 years, had long-standing, slowly progressive dysphagia and aspiration; one patient had recurrent episodes of aspiration pneumonia as a result. Both patients were diagnosed on videofluoroscopy with large bony anterior cervical osteophytes. Immediate relief of symptoms was obtained after resection of the osteophytes via an anterolateral, extrapharyngeal approach. Anterior cervical osteophytes are relatively common in the elderly, although not frequently diagnosed, and are mostly seen in cases of diffuse idiopathic skeletal hyperostosis. If therapy is indicated it is mainly conservative; resection is rarely needed.

In patients with anterior cervical osteophytes, surgical treatment is indicated only for selected cases with large, bony osteophytes and severe symptoms.

Bone-anchored hearing aid surgery in younger children is a two-stage procedure, with a titanium fixture being allowed to osseointegrate for several months before an abutment is fitted through a skin graft. In the first procedure, it has been usual to place a reserve or sleeper fixture approximately 5 mm from the primary fixture as a backup in case the primary fixture fails to osseointegrate. This ipsilateral sleeper fixture is expensive, is often not used, and is placed in thinner calvarial bone where it is less likely to osseointegrate successfully. The authors have implanted the sleeper fixture on the contralateral side, with the additional objective of reducing the number of procedures for bilateral bone-anchored hearing aid implantation, providing a cost-effective use for the sleeper.

The authors implanted the bone-anchored hearing aid sleeper fixture in the contralateral temporal bone instead of on the ipsilateral side in seven successive paediatric cases with bilateral conductive hearing loss requiring two-stage bone-anchored hearing aids, treated at the Royal Manchester Children's Hospital, UK.

The seven patients ranged in age from five to 15 years, with a mean age of 10 years; in addition, a 20-year-old with learning disability was also treated. In each case, the contralateral sleeper fixture was not needed as a backup fixture, but was used in four patients (57 per cent) as the basis for a second-side bone-anchored hearing aid.

In children with bilateral conductive hearing loss, in whom a bilateral bone-anchored hearing aid is being considered and the second side is to be operated upon at a later date, we recommend placing the sleeper fixture on the contralateral side at the time of primary first-side surgery. Our technique provides a sleeper fixture located in an optimal position, where it also offers the option of use for a second-side bone-anchored hearing aid and reduces the number of procedures needed.

This case is reported in order to demonstrate the importance of detailed clinical analysis, including evaluation of personal and family history, in the differential diagnosis of sudden sensorineural hearing loss.

A 50-year-old woman presented with a sudden onset of sensorineural hearing loss in her right ear. She had experienced three previous episodes of sudden sensorineural hearing loss in her left ear, at the ages of 35, 48 and 50 years. She also reported suffering two strokes with left hemiparesis due to fibromuscular dysplasia of her right internal carotid artery. A positive family history of stroke among maternal relatives suggested autosomal dominant inheritance. The patient's personal and family history suggested a rare cause of sudden sensorineural hearing loss, for which alternative therapeutic modalities may be applicable in selected cases.

Careful follow up of any patient with sudden sensorineural hearing loss and evaluation of their personal and family history is essential, in order to uncover evidence of rare underlying causes of sudden sensorineural hearing loss. For patients with such rare diagnoses, alternative therapy and surveillance modalities may be useful in disease management, depending on pre-existing pathology. Those patients should be managed via a multidisciplinary approach, including genetic counselling, in order to achieve the best possible outcome.

We report a rare case of auricular involvement by leishmaniasis, in order to demonstrate the importance of thorough investigation of cutaneous head and neck lesions, and also the importance of inclusion of infections such as leishmaniasis in the differential diagnosis of auricular lesions, especially in endemic areas.

A 42-year-old man with multiple lesions on his head, neck and hands was referred to our centre. He had the following lesions: a painful, crusted, 8 × 8 cm plaque with indurated margins on the left parotid region and auricle; a red papule on the right temporal region; an ulcerative lesion on the skin overlying the proximal interphalangeal joint of the fifth finger of the right hand; and a bluish papule on the neck. Although histopathological examination of the Geimsa-stained specimen was misleading, a direct smear prepared from biopsies showed amastigotes, and therapy resulted in complete recovery.

Leishmaniasis can be both under- or over-diagnosed. Especially in endemic areas, parasitic causes of chronic infections should always be kept in mind.

To present a rare case of rectal adenocarcinoma metastasising to the external auditory canal, in a patient in whom computed tomography staging of the abdomen, chest and pelvis was clear for metastatic disease.

Case report and review of the literature.

Metastatic tumours to the external auditory canal are rare, with rectal adenocarcinoma being one of the rarest. However, it is important that the external auditory canal is regarded as a potential site for metastasis, even when computed tomography staging is clear. Metastatic tumour should be included in the differential diagnosis of a patient presenting with an ear mass.

Asthma treatment has the potential to affect patients' voices. We undertook detailed characterisation of voice morbidity in patients attending a problem asthma clinic, and we determined how patients' perceptions related to objective assessment by an experienced observer.

Forty-three patients took part in the study. Subjects completed the self-administered voice symptom score (VoiSS) questionnaire and underwent digital voice recording. These voice recordings were scored using the grade–roughness–breathiness–asthenicity–strain system (GRBAS). Laryngoscopy was also performed.

The median VoiSS was 26 (range three to 83). VoiSS were significantly lower in the 17 patients with normal laryngeal structure and function (range four to 46; median 22), compared with the 26 patients with functional or structural laryngeal abnormality (range three to 83; median 33) (95 per cent confidence intervals for difference 0.0–21.0; p = 0.044). The overall grade score for the GRBAS scale did not differ between these two groups, and only 13 patients had a GRBAS score of one or more, recognised as indicating a voice problem. There were positive correlations between related GRBAS score and voice symptom score subscales. Although voice symptom scores were significantly more abnormal in patients with structural and functional abnormalities, this score performed only moderately well as a predictive tool (sensitivity 54 per cent; specificity 71 per cent). Nevertheless, the voice symptom score performed as well as the more labour-intensive GRBAS score (sensitivity 57 per cent; specificity 60 per cent). Patients' inhaled corticosteroid dose (median dose 1000 µg beclomethasone dipropionate or equivalent) had a statistically significant relationship with their overall grade score for the GRBAS scale (r = 0.56; p < 0.001), but not with their VoiSS. Only one patient had evidence of laryngeal candidiasis, and only two had any evidence of abnormality suggesting steroid-induced myopathy.

Vocal morbidity is common in patients with asthma, and should not be immediately attributed to steroid-related candidiasis. The VoiSS merits further, prospective validation as a screening tool for ENT and/or speech and language therapy referral in patients with asthma.

To report an unrecognised complication of fibre-optic nasendoscopy, and its management.

A protective, transparent nasendoscopy sheath is often used to reduce nasendoscope ‘downtime’ and to prevent cross infection, with minimal effect on the obtained image quality. We report the case of a subcutaneous tracheostomy procedure during which, without undue strain, the tip of the sheath became detached and acted as a foreign body within the trachea. A urological stone retrieval basket was used to retrieve the sheath, after failure of conventional methods.

Clinicians should be aware that any instrument introduced into the airway has the potential to fail and in the process produce a foreign body which may cause serious complications. The urological stone retrieval basket may be a useful addition to the current set of instruments used to deal with difficult airway foreign bodies.