The development of computer-aided systems for endoscopic sinus surgery has enabled surgical navigation through diseased or surgically altered sinus anatomy with increased confidence. However, conventional computer-aided systems do not provide intra-operative updated computed tomography imaging. We describe the technical aspects of the xCAT™, a new intra-operative mobile volume computed tomography scanner.

A patient with a malignant melanoma unwittingly removed at another hospital underwent surgery for removal of the lateral nasal wall and directed biopsies, in an attempt to identify the site of tumour origin. The procedure was performed with the GE InstaTrak 3500 PlusTM computer-aided system, updated with intra-operative computed tomography images. Intra-operative, updated images were integrated successfully into the InstaTrak system, and these images were consistent with the observed endoscopic anatomy.

The xCAT intra-operative mobile volume computed tomography scanner is a technological advancement that can assist the endoscopic sinus surgeon when performing complex rhinological and skull base procedures.

To evaluate the type of aerobic bacteria commonly isolated from peritonsillar abscesses.

A retrospective study involving 60 patients presenting with peritonsillar abscess treated between 2003 and 2006.

The patients were treated in a tertiary care, teaching hospital. The records of the patients were reviewed and analysed.

Gram-positive organisms were commonly isolated from the abscesses. However, an increasing trend towards Gram-negative bacterial isolates was noted. The antibiogram showed changing patterns of sensitivity, with a resistance to penicillin.

There is an increasing incidence of Gram-negative aerobic bacteria causing peritonsillar abscess. Appropriate antibiotics for Gram-negative bacteria should be included in the regimen if such bacteria are isolated in culture and sensitivity studies.

Empirical antibiotics with Gram-negative cover will be appropriate as adjunctive therapy.

To evaluate hearing changes during ‘wait and scan’ management of patients with vestibular schwannoma.

Over a 10-year period, 636 patients have prospectively been allocated to ‘wait and scan’ management, with annual magnetic resonance scanning and audiological examination.

At the time of diagnosis, 334 patients (53 per cent) had good hearing and speech discrimination of better than 70 per cent; at the end of the 10-year observation period, this latter percentage was 31 per cent. In 17 per cent of the patients, speech discrimination at diagnosis was 100 per cent; of these, 88 per cent still had good hearing at the end of the observation period. However, in patients with even a small initial speech discrimination loss, only 55 per cent maintained good hearing at the end of the observation period.

After comparing the hearing results of hearing preservation surgery and of radiation therapy with those of ‘wait and scan’ management, it appears that, in vestibular schwannoma patients with a small tumour and normal speech discrimination, the main indication for active treatment should be established tumour growth.

Coblation tonsillectomy is a relatively recently introduced surgical technique which attempts to bridge the gap between ‘hot’ and ‘cold’ tonsillectomy methods.

To compare coblation tonsillectomy with three commonly used surgical techniques: cold dissection–ligation, monopolar electrocautery and CO2 laser.

A prospective, randomised, double-blinded clinical trial was undertaken of 60 adult patients divided into three equal study groups. Patients in each group were randomly assigned to have one tonsil removed with coblation and the second with one of the other three tonsillectomy techniques. Ten randomly selected tonsils resected by each method were sent for histopathological evaluation.

Coblation was significantly faster to perform than laser and produced significantly less intra-operative blood loss than both the dissection–ligation and laser techniques. Subjective visual analogue scale comparisons showed a non-significant pain score difference between coblation and dissection–ligation on most post-operative days. Coblation produced consistently highly significantly (p < 0.001) less pain, compared with electrocautery up to the 12th post-operative day and laser up to the 10th post-operative day. There was no significant difference in tonsillar fossa healing, comparing coblation to both dissection–ligation and laser techniques. Monopolar electrocautery produced significantly slower healing than coblation after 7 post-operative days, with no significant difference after 15 post-operative days. Histopathological evaluation showed that coblation inflicted significantly less thermal tissue injury than either electrocautery (p = 0.001) or laser (p = 0.003).

In adult patients, coblation tonsillectomy offers some significant advantages in terms of post-operative pain and healing, compared with other tonsillectomy techniques.

Acute tonsillitis or pharyngitis may lead to suppurative thrombophlebitis of the internal jugular vein. This complication, also known as Lemierre's syndrome, remains, even nowadays, life threatening, due to dissemination of septic thromboemboli to various organs. Respiratory deficiency and renal impairment are often reported in patients suffering from Lemierre's syndrome.

The unusual clinical manifestation of this case involves severe acute renal and respiratory deficiency in addition to microangiopathic consumption coagulopathy in a young patient treated with macrolides five days after the onset of acute tonsillitis.

The usual causative pathogen, namely Fusobacterium necrophorum, shows a varying sensitivity to macrolides. As a result, the syndrome may present itself in a variety of clinical forms even in patients under treatment with macrolides. A high index of suspicion is therefore crucial for in time prevention of potentially life threatening complications.

To assess benefit from one and three months' empirical proton pump inhibitor treatment in patients with suspected laryngopharyngeal reflux, and to define pre-therapy factors which may predict success with short-term proton pump inhibitor treatment.

Prospective, open clinical study.

One hundred adult out-patients with suspected laryngopharyngeal reflux were enrolled in the study. Laryngopharyngeal reflux patients underwent endoscopy and received omeprazole for three months. Efficacy of treatment was assessed at one and three months. Patients were classified as responders if their total symptom score had improved at least 50 per cent, their videolaryngoscopic score had improved by at least two points, and they were satisfied with the results. Pre-therapy factors assessed for an effect on omeprazole outcomes included: patient demographics, reflux symptoms, videolaryngoscopic scores, endoscopic findings, overall vocal dysfunction degree, self-rated voice handicap index, hospital anxiety and depression scale scores, and general well-being score.

Fifty-six per cent of patients were classified as responders at one month of treatment; this proportion rose to 92 per cent at three months. Those patients entering the study with a higher heartburn score showed a significant response after one month of omeprazole treatment. Non-responders were found to have significantly more anxiety than responders. Logistic regression analysis revealed these factors, plus the medication dose, as being relevant for faster response prediction. No significant association was found between pre-therapy factors and three-month response to proton pump inhibitor treatment.

Three months of proton pump inhibitor treatment twice daily is warranted for confirming suspicion of laryngopharyngeal reflux. Baseline anxiety levels and heartburn scores, and the medication dose, may be relevant factors when predicting faster response to proton pump inhibitor treatment in carefully selected patients.

Enlarged tonsils and adenoids (part of Waldeyer's ring) are responsible for obstructive sleep disordered breathing. Obstructive sleep disordered breathing episodes lead to hypoxaemia, hypercapnia and a state of arousal, all of which affect normal development of the nervous system. In this study, two hypotheses were tested: (1) obstructive sleep disordered breathing is caused by adenotonsillar hypertrophy and is associated with hypoxia and brain dysfunction; and (2) children with obstructive sleep disordered breathing more commonly display emotional lability, depressive behaviour and anxiety.

A total of 225 children were examined. The study group consisted of 121 children with adenotonsillar hypertrophy (87 aged six to nine years and 34 aged 10 to 13 years) and with obstructive sleep apnoeas and hypopnoeas confirmed by polysomnography. Patients were compared with 104 children with no obstructive sleep disordered breathing and no adenotonsillar hypertrophy (74 aged six to nine years and 30 aged 10 to 13 years). The following tests were used to measure the children's emotional disorders: the children's depression inventory; the state-trait anxiety inventory for children; and the emotional instability scale. The average values and standard deviations were calculated for all results. Student's t-test was used to compare differences in all groups of children. The minimum level of p < 0.05 was set as statistically significant.

Children with adenotonsillar hypertrophy are more likely to experience poor brain development and sleep problems. They also have emotional disturbances. In the sick and healthy children aged six to nine years, mean results for the emotional instability scale were statistically significantly different in the two groups, being higher in children with adenotonsillar hypertrophy than in healthy children. Mean values for the children's depression inventory test were higher in children with adenotonsillar hypertrophy, but the differences were not statistically significant. In the state-trait anxiety inventory for children test, the mean T score was T = 1.760 and the level of significance was p = 0.08 for both groups. Since the standard level of significance was p < 0.05, the differences in mean values for the state-trait anxiety inventory for children test bordered on statistical significance. There were no differences between tests results in the older children (10 to 13 years).

Recent studies have confirmed the negative emotional effect of adenotonsillar hypertrophy induced obstructive sleep disordered breathing in children aged six to nine years. The main problems are emotional lability, and anxiety and depressive disturbances. Such emotional problems subside in older children (aged 10 to 13 years).

To compare the effect of remifentanil combined with desflurane or isoflurane on the quality of the operative field and surgical conditions, blood loss, and recovery during tympanoplasty or endoscopic sinus surgery.

Randomised, double-blinded clinical study.

Sixty-four patients were scheduled for elective tympanoplasty or endoscopic sinus surgery. The patients were randomly divided into two groups: desflurane or isoflurane. After anaesthesia induction, all patients received a continuous remifentanil infusion of 0.2–0.5 µg/kg/min until a mean arterial pressure of 65–75 mmHg was achieved. Heart rate and mean arterial pressure were recorded throughout anaesthesia. Blood loss was measured at the end of surgery. Achievement of a bloodless operative field was rated on a 100 mm visual analogue scale. Following completion of surgery, the time to extubation and to achievement of an Aldrete score of nine or more was recorded.

Sixty-three patients were evaluated. The total dose of remifentanil and the total blood loss were similar in both groups (p > 0.05). Time to extubation and to an Aldrete score of nine or more for the desflurane group was significantly less than for the isoflurane group (p < 0.05). No differences were found in the extent of achievement of a bloodless operative field, as assessed via visual analogue scale, comparing the study groups (p > 0.05).

Although desflurane and isoflurane both enabled good surgical conditions (in terms of quality of operative field) and convenient induction of hypotension for tympanoplasty and endoscopic sinus surgery, the recovery characteristics of desflurane were better than those of isoflurane. Therefore, desflurane may be preferable to isoflurane in such circumstances.

We report a case of a 58-year-old man suffering from stiff-person syndrome and recurrent peripheral vertigo.

A case report and a review of the recent literature on stiff-person syndrome are presented.

The patient presented with recurrent episodes of vertigo with a pure peripheral pattern and with concomitant episodes of burning muscle pain, muscle twitching, weight gain and fatigue, worsening with tension or stress that also occurred in periods without vertigo. Cochlear examinations only showed presbyacusis-like hearing loss. The diagnosis of stiff-person syndrome was made with electromyographic examination and from findings in the blood and cerebrospinal fluid of high titres of anti-glutamic acid decarboxylase (GAD67) autoantibodies. In a two-year follow-up period, therapy for stiff-person syndrome abolished episodes of both stiffness and vertigo.

As far as we know, no other clinical case of acute vestibular damage with a possible correlation with anti-glutamic acid decarboxylase antibodies has been described. Peripheral vertigo possibly related to a lack of gamma aminobutyric acid underlines a possible role of gamma aminobutyric acid as a neurotransmitter in the peripheral vestibular system.

Post-tonsillectomy morbidity statistics are obtained when patients present to hospital with complications. The two common morbidities are pain and haemorrhage. Hospital-recorded morbidity rates may be an underestimation, as some patients are treated by general practitioners and are therefore not included in hospital audits.

Prospective, cohort, questionnaire study to assess: the post-tonsillectomy haemorrhage rate (i.e. actual rate versus hospital recorded rate); and the number of patients with post-operative pain and/or bleeding who were treated with antibiotics by their general practitioner.

The response rate was 76 per cent (70/92). The actual rate of secondary haemorrhage was three times that noted in the hospital records (15.7 vs 5.7 per cent, respectively). Fifteen patients (21 per cent) required extra analgesia after discharge. General practitioners prescribed antibiotics for pain alone in six patients (11 per cent).

The actual post-tonsillectomy haemorrhage rate is much higher than that recorded in hospital statistics. General practitioners differ in their treatment of post-tonsillectomy patients presenting with pain alone; some prescribe antibiotics in addition to analgesia.

Embryological remnants of third or fourth branchial pouches are a rare but important cause of recurrent neck abscesses in children. They are characterised by an internal opening in the piriform fossa. Traditional management involves surgical excision of the entire tract. We present our experience with the use of monopolar diathermy applied to the internal sinus opening as a treatment modality for this condition.

A retrospective, case report review was performed.

Four cases of piriform fossa sinus were treated with monopolar diathermy to the sinus opening via an endoscopic approach. The first three cases were treated in this way for recurrence, following external tract excision, while the fourth case had simultaneous excision of the tract and diathermy to the piriform fossa opening. There were no serious complications and no recurrence within a follow-up period ranging from nine to 27 months.

Obliteration of the internal opening of these sinuses by endoscopic diathermy is a safe and effective management option for this condition, either as an alternative to or as an adjunct to external surgical excision of the tract.

Within the United Kingdom, there are 50 000 practitioners of complementary and alternative medicine, with five million people consulting these practitioners yearly. The aim of this study was to explore the use of such therapies by patients attending a head and neck oncology clinic in Aberdeen.

Questionnaires were distributed to 200 patients over an eight-week period. The questionnaire consisted of questions regarding: demographic factors; 48 listed herbal preparations and alternative therapies; reasons for their use; and opinions on their efficacy.

One hundred and thirty-eight patients completed the questionnaires. Fifty per cent (69/138) of respondents had used complementary and alternative medicine previously, with 26 per cent having used it in the preceding year. Fifty-five per cent of respondents learned about complementary and alternative medicine use from friends, and the majority obtained such medicines by purchasing from a shop. Fifty per cent (34/69) of respondents stated that their family physician was unaware of their use of complementary and alternative medicine.

All medical practitioners should be aware of increasing complementary and alternative medicine usage by the United Kingdom population, and should be able to counsel patients appropriately.

To measure patient-reported quality of life before and after botulinum toxin A treatment of post-parotidectomy Frey's syndrome (gustatory sweating).

A questionnaire concerning functional, social and emotional aspects of Frey's syndrome (14 questions, with responses on a zero to three point scale) was administered to 17 patients (13 women and four men) before and one month after intradermal injection of botulinum toxin A. Parotidectomy had been performed one to 19 years previously, for benign (n = 10) or malignant (n = 7) tumours, with gustatory sweating occurring a median of 15 months after surgery (range: one month to 14 years). Pre- and post-treatment quality of life scores were compared using Wilcoxon's test (p < 0.05).

Patients' reported functional quality of life improved significantly (p = 0.0004). Their social and emotional scores were not significantly modified (p = 0.155 and 0.142, respectively). Seven patients (41 per cent) found the injections painful, but all patients said that the effects were beneficial, that they would undergo new injections if necessary and that they would recommend this treatment to other patients. The benefit lasted over 1.5 years for 60 per cent of patients. No correlation was found between duration of the effect and the extent of parotidectomy (p = 0.067).

Botulinum toxin A significantly improved patients' functional quality of life, without significant improvement in their social or emotional quality of life, according to our questionnaire results. The duration of the effect was longer than the reported physiological effect of botulinum toxin A on acetylcholine receptors.

To identify if there is a link between bacterial colonisation of the tonsillar fossa and post-tonsillectomy haemorrhage.

Prospective non-interventional study of 105 patients who underwent tonsillectomy during a seven-month period. The study took place in a secondary care centre, the West Middlesex University Hospital.

The participants were 105 patients who consecutively underwent tonsillectomy. The exclusion criteria were any patients with suspected or known malignancy, or known bleeding dyscrasias. The participants underwent microbiological sampling of the tonsil pre-operatively.

The outcome measures were primary or secondary bleeding, defined as any evidence of haemorrhage in the tonsillar fossae.

Twenty-four per cent of patients undergoing tonsillectomy had positive cultures from their tonsils pre-operatively. Patients with bacterial colonisation of the tonsillar fossa pre-operatively had an increased rate of post-tonsillectomy haemorrhage (odds ratio: 3.8, 1.1–12.1, 95 per cent confidence intervals, p = 0.04).

This prospective study has found a relationship between bacterial colonisation of the tonsillar fossa and post-tonsillectomy haemorrhage. This suggests that there may be an argument for the use of antibiotics in those cases with positive pre-operative cultures. In view of the types of pathogens isolated, we feel that the management of a post-tonsillectomy bleed should include a beta lactamase inhibiting antibiotic.

Malignant triton tumour is a relatively rare, aggressive sarcoma comprising both malignant schwannoma cells and malignant rhabdomyoblasts. Malignant triton tumour of the parapharyngeal space is exceptionally rare, with only one case being described in the literature. Malignant triton tumour of the cervical sympathetic nerve has not previously been reported.

We report a case involving the parapharyngeal space and arising from the cervical sympathetic nerve, and we review the management and outcome of the previous case reported in this rare location.

The parapharyngeal space is a unique location. Owing to this specific localisation, adjuvant therapy in addition to complete resection may be important in the treatment of malignant triton tumour in this rare location.

To analyse the circumstances of mortality in post-tonsillectomy bleeding cases, in order to better manage serious problems during resuscitation.

Reports of inquiry committees on post-tonsillectomy mortalities.

State of Israel Ministry of Health committees.

Senior otolaryngologists and related professionals, and the involved medical staff who participated in the inquiry committees.

Identification of actions causing undesirable effects on resuscitation outcomes.

In recent years, the post-tonsillectomy mortality rate in Israel has been one in 12 000. The two main causes of death have been severe haemorrhagic shock and airway obstruction.

Active bleeding should be treated, rather than waiting for spontaneous resolution. An efficient airway should be established early during resuscitation, either by intubation (within two minutes) or by cricothyroidotomy. The two main factors endangering the patient's life during resuscitation are severe blood loss, interfering with effective cardiac output, and airway obstruction. Blood loss should be quickly substituted.

The buccinator musculomucosal flap is an axial-pattern flap based on either the buccal or the facial artery. We present our experience with this flap and describe its surgical anatomy, the surgical techniques utilised to raise the flap and its clinical applications.

We retrospectively reviewed all patients who had had buccinator myomucosal flaps created at the Groote Schuur Hospital between 1999 and 2004. Patients were also recalled to assess flap sensation and to record reduction of mouth opening as a consequence of donor site scarring.

Of the 14 patients who had had a buccinator myomucosal flap created, there was one flap failure. Sensation was present in 71 per cent of flaps, and there was no trismus due to donor site scarring.

The buccinator myomycosal flap is a dependable flap with good functional outcome and low morbidity.