A large case series of temporal bone fractures at a UK major trauma centre with an evidence-based management protocol.

OBJECTIVE: To review the management of temporal bone fractures at a major trauma centre and introduce an evidence-based protocol. METHODS: A review of reports of head computed tomography performed for trauma from January 2012 to July 2018 was conducted. Recorded data fields included: mode of trauma, patient age, associated intracranial injury, mortality, temporal bone fracture pattern, symptoms and intervention. RESULTS: Of 815 temporal bone fracture cases, records for 165 patients met the inclusion criteria; detailed analysis was performed on the records of these patients. CONCLUSION: Temporal bone fractures represent high-energy trauma. Initial management focuses on stabilisation of the patient and treatment of associated intracranial injury. Acute ENT intervention is directed towards the management of facial palsy and cerebrospinal fluid leak, and often requires multidisciplinary team input. The role of nerve conduction assessment for immediate facial palsy is variable across the UK. The administration of high-dose steroids in patients with temporal bone fracture and intracranial injury is not advised. A robust evidence-based approach is introduced for the management of significant ENT complications associated with temporal bone fractures.

Audiovisual distraction reduces pain perception during aural microsuction.

INTRODUCTION: Aural microsuction is a common ear, nose and throat procedure used in the outpatient setting. Some patients, however, find it difficult to tolerate owing to discomfort, pain or noise. This study evaluated the effect of audiovisual distraction on patients' pain perception and overall satisfaction. METHODS: A prospective study was conducted for patients attending our aural care clinic requiring aural toileting of bilateral mastoid cavities over a three-month period. All microsuction was performed by a single clinical nurse specialist. Any patients with active infection were excluded. For each patient, during microsuction of one ear, they watched the procedure on a television screen while for the other ear they did not view the procedure. All patients received the same real time explanations during microsuction of both ears. After the procedure, each patient completed a visual analogue scale (VAS) to rate the pain they experienced for each ear, with and without access to the television screen. They also documented their preference and reasons why. RESULTS: A total of 37 patients were included in the study. The mean pain score for patients viewing the procedure was 2.43 compared with a mean of 3.48 for patients with no television view. This difference in patients' pain perception was statistically lower in the group who observed the procedure on the television (p=0.003), consistent with the majority of patients reporting a preference to viewing their procedure (65%). CONCLUSIONS: Audiovisual distraction significantly lowered patients' VAS pain scores during aural microsuction. This simple intervention can therefore reduce patients' perceived pain and help improve acceptance of this procedure.

Hearing and ossicular chain preservation in cholesteatoma surgery.

OBJECTIVE: To assess the hearing changes associated with sacrificing an intact ossicular chain during cholesteatoma surgery. METHODS: We reviewed the operation notes of surgical procedures performed by the senior author between October 2000 and April 2006. Thirty-three cases were identified in which cholesteatoma surgery had been performed in the presence of a mobile, intact ossicular chain. One set of case notes was missing; therefore, 32 cases were included in the analysis. The ossicular chain was preserved in 17 cases (14 males and three females) and sacrificed in 15 (eight males and seven females). RESULTS: At the first post-operative assessment, a median air-bone gap deterioration of 3.3 dB was seen in patients in whom the ossicular chain had been sacrificed, while a median air-bone gap improvement of 3.3 dB was seen in those in whom the chain had been preserved. However, multivariable logistic regression analysis suggested that this difference in hearing outcomes was due to pre-operative hearing status, and that preservation of the ossicular chain did not lead to a better outcome. CONCLUSIONS: In cholesteatoma surgery, there is at most a marginal benefit in preserving the ossicular chain. In the current study, the better hearing outcomes associated with preservation of the ossicular chain were accounted for by patients' better pre-operative hearing status. This study did not demonstrate a difference in residual disease rate, but was underpowered to do so.

Bilateral profound sudden sensorineural hearing loss presenting a diagnostic conundrum in a child with sickle cell anaemia.

OBJECTIVE: To present the first published case of a child with bilateral profound sudden sensorineural hearing loss found in association with sickle cell anaemia, and to demonstrate the importance of early recognition, investigation and empirical treatment of sudden sensorineural hearing loss. METHOD: Case report and review of world literature. CASE REPORT: The authors present the case of a seven-year-old child with known sickle cell anaemia, who presented with bilateral profound sensorineural hearing loss developing over a period of five days. There was a history of ophthalmological disease in the preceding weeks, and inflammatory markers were raised. The differential diagnosis included a vaso-occlusive or inflammatory aetiology such as Cogan's syndrome, and treatment for both was instigated. Hearing thresholds did not recover, and the patient underwent cochlear implantation 12 weeks later. CONCLUSION: Sudden sensorineural hearing loss has a variable aetiology and is rare in children. Immediate treatment for all possible aetiologies is essential, along with targeted investigations and early referral for cochlear implantation if no recovery is demonstrated.

Keratosis obturans and external ear canal cholesteatoma: how and why we should distinguish between these conditions.

Keratosis obturans and external ear canal cholesteatomas have been considered as separate entities for the last 20 years, after being regarded as variations of the same disease for at least 87 years. While both disorders are distinct, they do have some overlapping characteristics which may make it difficult to reach a definite diagnosis. This review explores the diagnostic dilemmas which may arise, and discusses the classification, aetiology, pathogenesis and management of these conditions. We concur that external ear canal cholesteatoma and keratosis obturans are different conditions and conclude that the presence of osteonecrosis and focal overlying epithelial loss are the most reliable features favouring the diagnosis of external ear canal cholesteatoma over keratosis obturans. Furthermore, whilst keratosis obturans can be managed successfully by regular aural toilet, external ear canal cholesteatoma may require surgical intervention depending on the extent of the disease.

Epistaxis as a rare presenting feature of glomus tympanicum.

Glomus tumours are the most common primary neoplasms of the middle ear, typically benign and slowly progressive. Pulsatile tinnitus and ipsilateral hearing loss are the most common symptoms at presentation by far; otalgia, aural fullness and otorrhoea being less frequent. A case of primary glomus tympanicum presenting with recurrent epistaxis, previously unreported in the literature, is described and associated imaging presented.

Intratympanic gentamicin for Ménière's disease; a survey of current UK practice.

Intratympanic gentamicin is increasingly used in the treatment of Ménière's disease. Many protocols have been published for its use, but there is little difference in outcome between them. The goal of the study was therefore to assess current UK practice in the use of intratympanic gentamicin. A postal and e-mail survey of consultant ENT surgeons in the UK was conducted. Of 34 consultants who regularly used intratympanic gentamicin, 21 used a protocol based upon a single intratympanic dose of gentamicin via a needle through the tympanic membrane and repeated after at least a week. The remaining 13 used either a regime of more frequent administration or attempted a more complicated route of delivery in an effort to improve reliability and selectivity of action. In the absence of evidence demonstrating benefit from regimens of increased complexity the majority of consultants are using the simplest possible protocol.

Meningioma in the internal auditory canal.

A case is presented of an entirely intracanalicular meningioma in a 48-year-old woman that was excised via a conventional translabyrinthine approach to the internal auditory canal (IAC). Pre-operative magnetic resonance imaging (MRI) suggested that the tumour was a vestibular schwannoma (VS). Histological examination confirmed the intra-operative impression that the tumour was a meningioma. Although VS is by far the commonest intracanalicular tumour, the differential diagnosis includes meningioma. MRI is unable to distinguish between these two entities when the tumour is located entirely in the internal auditory canal.

Long-term middle-ear effects of middle-ear/eustachian tube packing after translabyrinthine surgery.

The purpose of this study was to evaluate the long-term effect on middle ear and eustachian tube function following the packing of the middle-ear space to prevent cerebrospinal fluid rhinorrhoea at the termination of translabyrinthine vestibular schwannoma removal. This was an observational study of a sample of 14 patients examined between two and five years post-operatively. Photo-otoscopy and tympanometry were performed bilaterally to evaluate appearance and function. All operated middle ears were air-containing although eight out of 14 showed scarring as evidence of operative intervention. There were no drum retractions. Ten out of 14 middle-ear compliance peaks were lower in the operated ear with four flat traces. Two out of 14 were the same and two out of 14 showed high compliance. The middle-ear pressure was always within the normal range when determinable. This technique appears to have no detrimental effects on the middle ear and does not permanently obliterate the eustachian tube. The reduced compliance in the majority of cases is probably a result of scarring and fibrosis. When drum hypermobility is seen this is accounted for by incus removal.

Cochlear gene therapy: current perspectives.

Gene therapy has the potential to revolutionize therapy for hearing disorders. Advances in our understanding of the molecular basis of hearing combined with techniques for intracochlear gene transfer are leading us closer to clinical applications. Potential areas of interest are reviewed and experimental success using adeno-associated virus to effect intracochlear gene transfer is discussed.

Myxoid chondrosarcoma of the external auditory meatus.

Extraskeletal myxoid chondrosarcoma presenting in the head and neck is extremely rare. Histological diagnosis is difficult and requires close co-operation between clinician, radiologist and pathologist. The tumour has a good prognosis in comparison to myxoid chondrosarcoma of the bone but surgical resection may be difficult due to its gelatinous nature. We present a case of extraskeletal myxoid chondrosarcoma originating in the external auditory meatus of a 42-year-old man. This is the first report of this tumour in this site.

Laser assisted uvulopalatoplasty: six and eighteen month results.

Our ongoing evaluation of the results of laser assisted uvulopalatoplasty (LAUP) for snoring is presented. Follow-up between 18 and 24 months post-treatment completion, of patients with a successful result at six months, reveals that 22 per cent of these patients suffer failure of snoring control between these two evaluation points. This equates to an overall success rate at this time of 55 per cent. LAUP, like other surgical remedies for snoring, has a continued relapse rate. This must be considered when counselling patients.

The Clarion Multi-Strategy Cochlear Implant--surgical technique, complications, and results: a single institutional experience.

OBJECTIVE: This study aimed to review a single institution's experience with Clarion Multi-Strategy Cochlear Implant with respect to surgical technique, surgical complications, and rehabilitative outcome. STUDY DESIGN: This study was a review of patients implanted with the Clarion Multi-Strategy Cochlear Implant. SETTING: The setting was a tertiary referral center with care delivered in the inpatient and outpatient environment. PATIENTS: The first 37 patients were implanted under an Investigational Device Exemption as part of the Food and Drug Administration (FDA) clinical trial of the Clarion implant. Subsequent patients were implanted after the device received FDA approval. Patients met the following criteria for implantation: 18 years of age or older, psychological and emotional stability, profound postlingual deafness without evidence of middle ear disease, one cochlea at least partially patent, and marginal or no benefit from conventional hearing aids. INTERVENTION: Patients received implantation with the Clarion Multi-Strategy Cochlear Implant. MAIN OUTCOME MEASURES: Measured were presence or absence of surgical complications and auditory performance with open- and closed-set word and sentence recognition testing. RESULTS: A total of 47 patients have been implanted. Three patients have suffered complications: two cases of delayed-onset facial palsy both resolved with steroid therapy and one case of internal cochlear stimulator migration required refixation. Significant improvement in speech understanding has been seen in the majority of patients who were implanted within the first 6 months of device use. Specifically, at 6 months, scores on CID (Central Institute for the Deaf) sentences (implant alone) improved from a preoperative mean of 9% to a mean of 72%, and scores on the NU-6 (Northwestern University) monosyllabic word test increased from a preoperative mean of 3% (range, 0-20%) to a mean of 32% (range, 0-70%). More than two thirds (68%) of the adults were able to understand at least 50% of sentences over the telephone, and half were able to understand at least 75% of the sentence material. CONCLUSIONS: The authors' institutional experience with the Clarion Multi-Strategy Cochlear Implant shows minimal surgical morbidity and significant improvement on all open-set test measures of sentence and word recognition.

Osteologic classification of the sphenopalatine foramen.

Textbook descriptions and illustrations of the opening of the sphenopalatine foramen (SPF) into the nasal cavity place it above and behind the posterior end of the middle turbinate (i.e., within the superior meatus). Although true for some skulls, this is not the situation for the majority and may be of importance, because the major blood supply to the nasal cavity enters via this route. Having studied 238 lateral nasal walls, the authors propose a classification of the osteology of the sphenopalatine foramen. In class I (35%) the opening of the SPF is purely into the superior meatus with a notch or foramen in the middle turbinate/ethmoidal crest of the palatine bone. In class II (56%) the SPF spans the ethmoidal crest (i.e., opens into both the superior and middle meati). In class III (9%) there are two separate openings into the superior and middle meati. These findings may explain the route of the artery to the inferior turbinate and indicate the need for care in dealing with the posterior end of the middle turbinate. They may also suggest a potential site for dealing with "difficult" epistaxis via an intranasal route.

Pyoderma gangrenosum producing saddle nose deformity.

Pyoderma gangrenosum affecting the nose is rare and this may lead to diagnostic confusion because of the large differential diagnosis. As diagnosis is made, largely, on the basis of exclusion the treatment of pyoderma gangrenosum may be unduly delayed. The condition is often disfiguring, particularly following inappropriate surgical intervention, and early diagnosis is therefore important. We present a case of pyoderma gangrenosum managed initially in the community with minor surgery and resulting in the rare complication of saddle nose deformity.

Psychogenic stridor: diagnosis and management.

Psychogenic stridor is a rare cause of apparent acute upper airway obstruction, usually occurring in young female adults. The alarming presence of inspiratory stridor leads to suspicion of organic disease, with urgent management directed towards treatment of suspected pathology. Careful history taking may suggest the correct diagnosis and early examination of the larynx, preferably by fibreoptic nasendoscopic examination, may identify the underlying abnormality of paradoxical adduction of the vocal cords on inspiration, accounting for the stridor. This characteristic feature allows a positive diagnosis to be made and may avoid potentially harmful and inappropriate interventions. Three cases are presented, illustrating an evolution of management.