Single-Stage BAHA and Mastoid Obliteration.

A single-stage fitting of a bone-anchored hearing aid (BAHA) implant and abutment with mastoid obliteration both obviates the need for two separate procedures and utilises the BAHA soft tissue reduction in the mastoid obliteration. Such a procedure has good outcomes in terms of osseointegration and achieving a dry ear. We present a 6-patient case series report highlighting the technique of combined BAHA insertion and mastoid obliteration in six patients. All patients at twelve-month followup have a good degree of sound localisation and hearing thresholds with their BAHA and are free from the social stigma associated with a foul smelling discharging ear.

Cautery of the tympanic membrane: the lesser known history of myringoplasty.

OBJECTIVE: To present the fascinating, controversial, and tumultuous history of tympanic cautery as a form of myringoplasty and describe the relevance of work more than 150 years old to modern practice and research. DATA SOURCES: More than 70 English, French, and German articles and books published over the last 400 years, which refer to some aspect of tympanic membrane cautery. HISTORY: The first recorded use of silver nitrate to stimulate closure of tympanic membrane perforations is by William Wilde in 1848. Since then, numerous modifications of this technique have been used, and its significance has waxed and waned in response to events within the speciality of otology and the wider world. CONCLUSION: There are lessons to be learned from the rise and fall of this once widely practiced technique. There exists a school of thought that believes that the significance of cautery lies not only in the history of otology but also in its future.

Diffusion-weighted magnetic resonance imaging in the management of cholesteatoma.

Diffusion-weighted (DW) MRI has recently increasingly gained popularity in the diagnosis of post-operative cholesteatoma. The aim of this study is to prospectively evaluate the usefulness of echo-planar imaging (EPI) for the diagnosis of residual cholesteatoma. Fifty patients underwent DW-EPI before surgery. Fifteen patients had a scan before their first surgery and 35 patients underwent neuroimaging prior to their second look surgery. In the first preoperative group of 15 patients, DW-EPI confirmed cholesteatoma in all the patients. In the post-operative group DW-EPI identified or excluded cholesteatoma correctly in 29 out of 35 patients. Our study has demonstrated a sensitivity of 83% and specificity of 82% of DW-EPI for the diagnosis of residual cholesteatoma. DW-EPI can be a value imaging modality and may help the surgeon in selecting patients for revision surgery.

Nasal injury management: an audit of accident and emergency practice.

Nasal injuries are commonly assessed in the accident and emergency (A&E) departments. Where swelling precludes assessment of deformity, patients are often referred to the ear, nose and throat (ENT) outpatients once the swelling has subsided. However, not all of these pateints require referral. Patients with no deformity, or those in whom there is no deformity after any swelling has subsided, do not need further assessment. The purpose of this audit was to assess the impact of a nasal injury management guideline on nasal injury referrals to the ENT department. An audit was made of nasal injury referrals seen in ENT outpatients, before and after the introduction of a guideline. The proportion of patients seen in ENT outpatients not requiring any ENT treatment after the introduction of the guideline was reduced. We suggest that our guideline can reduce unnecessary ENT outpatient appointments for patients with nasal injuries and may prevent delayed ENT input for those with new onset nasal deformity.

Pseudotumour of the temporal bone: an unusual [corrected] cause of otorrhoea and facial palsy.

An inflammatory pseudotumour of the temporal bone is a rare, idiopathic, fibro-inflammatory lesion which mimics malignancy. Although such a lesion is known to occur elsewhere in the body such as the liver, abdominal viscera, pelvis, thorax and the upper respiratory tract, the involvement of the temporal bone is extremely unusual. We present such a case in a 60-year-old man, which provided a great diagnostic challenge. We review the key radiological and histological results that confirmed the diagnosis and demonstrated for the first time that oral steroids alone may completely resolve the condition.

Spontaneous cerebrospinal fluid otorrhoea presenting as otitis externa.

A case of spontaneous cerebrospinal fluid (CSF) otorrhoea in a 59-year-old lady is reported. The patient was initially diagnosed and treated for chronic otitis externa. Following the referral by her GP, it was found that her symptom of otorrhoea was secondary to cerebrospinal fluid leak with middle ear encephalocoele. The CSF leak was repaired using a transmastoid approach with fascia, bone paté and fibrin glue. In this paper, we describe an unusual case of spontaneous CSF otorrhoea presenting as otitis externa. We review the pathophysiology of spontaneous CSF otorrhoea, and discuss the pitfalls in the diagnosis of CSF otorrhoea.

Laser excision of glomus tympanicum tumours: long-term results.

The purpose of this study was to evaluate the long-term results of laser excision of glomus tympanicum tumours in a series of patients who had been referred to the senior author (DAM) in a retrospective case review. Nine patients underwent complete excision of their glomus tympanicum tumours using a Diode or KTP laser. There were no cases of tumour recurrence. There were no complications during the peri- or postoperative period. Follow-up time was 31.8 months. In our experience, laser excision can be performed with minimal bleeding and morbidity, and it provides excellent tumour control in glomus tympanicum surgery.

Chondrosarcomas of the temporal bone: presentation and management.

Chondrosarcomas (CSA) of the temporal bone are rare primary malignant tumours that are slow growing, but locally aggressive. The management of CSAs involving the temporal bone is challenging and necessitates a multidisciplinary approach in a tertiary referral unit well practised in skull base surgery. Their management with particular reference to modes of presentation and treatment strategies has been reviewed here.

Far advanced otosclerosis and intractable benign paroxysmal positional vertigo treated with combined cochlear implantation and posterior semicircular canal occlusion.

This paper presents a combined procedure for the management of intractable benign paroxysmal positional vertigo (BPPV) and profound hearing loss in a patient with far advanced otosclerosis. The procedure comprised of a posterior semicircular canal occlusion and cochlear implantation as one combined procedure in the same ear. The combined approach added little to the operative morbidity and proved effective in this patient's management. A search of the literature reveals this to be a unique case.

Spontaneous arteriovenous malformation of the external auditory meatus.

Arteriovenous malformations (AVM) of the head and neck are rare. They usually occur intracranially and derive their vascular supply from the intracranial vessels. In the English literature there has not been any documented case of AVMs in and around the external auditory meatus (EAM). The authors present the first case, a spontaneous AVM deriving its vascular supply from the posterior auricular artery. The diagnostic difficulties and management strategies of spontaneous AVMs are discussed.

Bilateral submandibular duct relocation for drooling: an evaluation of results for the Birmingham Children's Hospital.

Drooling is a problem of the neurologically impaired that often leads to stigmatisation and social isolation. Bilateral submandibular duct relocation (BSMDR) is a surgical procedure that may be used to control troublesome drooling. The aim of this study was to assess the results following surgery and attempt to identify those factors that would mitigate against a successful outcome. A retrospective case note review was performed, and data were collected on 23 neurologically impaired patients who underwent the procedure between 1993 and 2000 at the Birmingham Children's Hospital, UK. An overall improvement in drooling was demonstrated in 20 (87%) cases, with complete cessation of drooling in 13 (57%) cases. The complications included one ranula, three transient submandibular gland swellings and two persistent swellings requiring gland excision. It is difficult to predict which patients will have an unsuccessful outcome following surgery. In our series, three (13%) patients had poor results. We could not determine any special features that could account for this, except that these patients in particular demonstrated the greatest degree of oral-motor dysfunction. BSMDR is a technically straightforward procedure associated with minimal morbidity and a high success rate. It is the procedure of choice at our institution.

Osseointegrated implants in the management of childhood ear abnormalities: with particular emphasis on complications.

Little has been published about the difficulties encountered during the insertion of osseointegrated implants for the attachment of bone anchored hearing aids (BAHA) and auricular prostheses in children. This study examines this issue in the first 51 children implanted at our centre. During surgery, the most common problem encountered was the presence of thin bone resulting in incomplete insertion of fixtures. Five fixtures had failed to integrate and six fixtures were lost in the long-term, however, only five children required revision surgery. The reason why few patients require revision was due to the judicious insertion of 'sleeper' fixtures. At follow-up, seven children required counselling for psychological problems. It is apparent from this study that osseointegrated implants in children are associated with difficulties, re-emphasizing that a paediatric osseointegration programme requires significant investment, and should only be undertaken by institutions that are committed to its success.

Dermoid cyst of the infratemporal fossa.

Dermoid cysts are rare benign tumours, they represent the simplest form of teratoma. Approximately seven per cent affect the head and neck region, within this region they are frequently encountered in the area of the lateral eyebrow, the orbit and the nose. A case of a 17-year-old girl who developed a rapidly growing facial swelling due to an infratemporal fossa dermoid cyst is presented. A review of the literature using Medline has not revealed any previous reports of similar cases. The lesion was completely excised using a lateral approach to the infratemporal fossa.

Updating concepts of first branchial cleft defects: a literature review.

OBJECTIVE: The Sinuses and fistulae of first branchial cleft origin have been widely reported in the literature and their variable relationship to the facial nerve has been described. Most published series however are too small to allow a detailed analysis of the relative frequency of various relationships of these lesions to the facial nerve and therefore enabling the determination of risks to the nerve at surgery. The aim of this study was to perform a comprehensive review of literature in an attempt to identify those patients with a deep tract (lying deep to the main trunk of the facial nerve and/or its branches, and/or between the branches) and to recognize the incidence of the complications of surgical management. METHODS: Available English, French and German literature between 1923 and 2000 was reviewed and variables including patient's age, sex, side and type of anomaly, opening of the lesion and the relationship of the tract are analyzed in relation to the position of the facial nerve. The complications due to their surgical excision are also reported. RESULTS: Of the total number of cases with fistulae and sinuses identified (n=158) fistulous tracts were more likely to lie deep to the facial nerve compared with sinus tracts (P=0.01). Lesions with openings in the external auditory meatus are associated with a tract superficial to the facial nerve (P=0.05). Patients presenting at a younger age were more likely to have a deep tract with consequent increased risk of facial nerve damage. CONCLUSION: Identification of the facial nerve trunk at an early stage of dissection is critical. Extra care and caution should be exercised in younger patients (<6 months), those with fistulous tracts and in patients with a tract opening elsewhere other than the external auditory canal.