To describe a useful technique for infiltrating a bulking agent using a butterfly needle, as part of a transoral endoscopic vocal fold medialisation procedure.

This paper describes the procedure of grasping the needle with phonosurgery forceps and administering the injectate to the vocal fold through careful application of the syringe plunger via a length of rubber tubing from outside the mouth.

This procedure is performed routinely in our institution without complication. The advantages of this technique are discussed.

This is a safe and easy method of injecting into a vocal fold.

To evaluate the utility of the hybrid tracheoesophageal puncture procedure in stapler-assisted laryngectomy.

Patients who underwent total laryngectomy at a single institution from 2009 to 2015 were reviewed. The interventions assessed were surgical creation of a tracheoesophageal puncture and placement of a voice prosthesis. The outcomes measured included voicing ability and valve failure.

Thirty-nine patients underwent total laryngectomy or pharyngolaryngectomy. Of these, nine underwent stapler-assisted laryngectomy; seven of the nine patients underwent concurrent stapler-assisted laryngectomy, cricopharyngeal myotomy and a hybrid tracheoesophageal puncture procedure. These seven patients were the focus of this review. Successful voicing and oral alimentation was achieved in all patients. Mean time to phonation was 30 days (range, 7–77 days) and mean time to first valve change was 90 days (range, 35–117 days).

Primary tracheoesophageal puncture with concurrent voice prosthesis placement and cricopharyngeal myotomy is easily performed with stapler-assisted laryngectomy. The hybrid tracheoesophageal puncture procedure is a simple method that enables a single operator to achieve primary tracheoesophageal puncture and valve placement; in addition, it facilitates concurrent cricopharyngeal myotomy.

Laryngotracheal stenosis is a complex condition of airway compromise involving either the larynx or trachea, or both.

This paper describes a new method of endoscopically inserting a silicone tracheal T-tube as treatment for laryngotracheal stenosis. The advantages of this method over previously described methods are discussed.

Careers in medicine are embarked on by people with various personalities, with highly strung and motivated characters usually drawn to surgery. This study was conducted to identify the personality types of ENT surgeons in comparison to a control group of foundation doctors.

A validated personality questionnaire was distributed to ENT specialty trainees and two cohorts of foundation doctors between October 2013 and November 2015. The questionnaires were scored and individuals were categorised as having either type A or type B personalities.

Response rates were 90 per cent (26 out of 29) for ENT specialty trainees and 76 per cent (79 out of 104) for foundation doctors. There was a significantly higher proportion of type A personalities in the ENT specialty trainees compared to the foundation doctors (18 out of 26 ENT specialty trainees vs 32 out of 79 foundation doctors; p = 0.01, chi-square = 6.4708). There were no associations between personality type and grade, gender or subspecialty of interest.

ENT surgeons are more likely to be of type A personality in comparison to foundation doctors. This could be a reflection of the recruitment process into the specialty or a characteristic of individuals that get drawn to ENT.

An increasing number of inexperienced doctors are rotating through otolaryngology departments and providing care to ENT patients. Numerous acute ENT conditions require basic surgical or technical intervention; hence, effective and efficient simulation induction training has become paramount in providing a safe yet valuable educational environment for the junior clinician. Whilst simulation has developed over the years for numerous ENT skills, to date there has not been a realistic and easily reproducible model for teaching the skills to manage one of the most common ENT emergencies, a peritonsillar abscess or ‘quinsy’.

We have adapted the Laryngotech trainer, a well-established ENT simulation tool, to present a readily accessible, reusable and realistic simulation model.

The model provides safe training for the drainage of quinsy.

Imaging the Eustachian tube has proven difficult as it has an anatomical orientation that is not aligned with standard planes. In addition, the Eustachian tube is a dynamic structure, opening briefly during a variety of physiological manoeuvres.

A 54-year-old healthy and asymptomatic man underwent computed tomography utilising an area detector scanner. Multiplanar reconstruction was performed at 1 mm intervals. In addition, dynamic clips were constructed to demonstrate air and its movement in the field. Images and video were acquired whilst a Valsalva manoeuvre was being performed.

Although imaging techniques have been able to visualise the Eustachian tube well in the closed state, it may be more useful to have it imaged whilst open. Area detector computed tomography scanners can be used to acquire four-dimensional images. This allows dynamic imaging of the region, to assist in the diagnosis of various types of Eustachian tube dysfunction.

Extracranial internal carotid artery pseudoaneurysm is very rare in children.

This paper discusses the case of a boy, aged two years and six months, who presented with an enlarging neck mass and unilateral bloody otorrhoea. Special investigations revealed an extracranial internal carotid artery pseudoaneurysm.

The patient made a full recovery after endovascular occlusion of the internal carotid artery and pseudoaneurysm using coils. At six months’ follow up, the internal carotid artery and pseudoaneurysm remained excluded from the circulation. The patient did not display any neurological deficits during hospital stay or follow up.

This paper reports on one of the youngest patients documented to date who presented with an internal carotid artery pseudoaneurysm, possibly secondary to ear infection. Although rare, this condition should be excluded in children presenting with a mass of the neck or pharynx because of the dire consequences if left undiagnosed and untreated.

• Radiotherapy (RT) and transoral laser microsurgery (TLM) are accepted treatment options for T1a–T2a glottic carcinoma. (R)

• Open partial surgery may have a role in the management of selected tumours. (R)

• Radiotherapy, TLM and transoral robotic surgery are reasonable treatment options for T1–T2 supraglottic carcinoma. (R)

• Supraglottic laryngectomy may have a role in the management of selected tumours. (R)

• Most patients with T2b–T3 glottic cancers are suitable for non-surgical larynx preservation therapies. (R)

• Concurrent chemoradiotherapy should be regarded as the standard of care for non-surgical management. (R)

• Subject to the availability of appropriate surgical expertise and multi-disciplinary rehabilitation services, TLM or open partial surgical procedures ± post-operative RT, may be also be appropriate in selected cases. (R)

• In the absence of clinical or radiological evidence of nodal disease, elective treatment (RT or surgery ± post-operative RT) is recommended to at least lymph node levels II, III and IV bilaterally. In node positive disease, it is recommended that lymph node levels II–V should be treated on the involved side. If level II nodes are involved, then elective irradiation of ipsilateral level Ib nodes may be considered. (R)

• Most patients with T3 supraglottic cancers are suitable for non-surgical larynx preservation therapies. (R)

• Concurrent chemoradiotherapy should be regarded as the standard of care for non-surgical management. (R)

• Subject to the availability of appropriate surgical expertise and multi-disciplinary rehabilitation services, TLM or open partial surgical procedures ± post-operative RT, may also be appropriate in selected cases. (R)

• In the absence of clinical or radiological evidence of nodal disease, elective treatment (RT or surgery ± post-operative RT) is recommended to at least lymph node levels II, III and IV bilaterally. In node positive disease, lymph node levels II–V should be treated on the involved side. (R)

• As per the PET-Neck clinical trial, patients with N2 or N3 neck disease who undergo treatment with chemoradiotherapy to their laryngeal primary and experience a complete response with a subsequent negative post-treatment positron emission tomography combined with computed tomography (PET–CT) scan do not require an elective neck dissection. In contrast, patients who have a partial response to treatment or have increased uptake on a post-treatment PET–CT scan should have a neck dissection. (R)

• Larynx preservation with concurrent chemoradiotherapy should be considered for T4 tumours, unless there is tumour invasion through cartilage into the soft tissues of the neck, in which case total laryngectomy yields better outcomes. (R)

• In the absence of clinical or radiological evidence of nodal disease, elective treatment (RT or surgery ± post-operative RT) is recommended to bilateral lymph node levels II, III, IV, V and VI. (R)

Sensorineural hearing loss is a recognised complication of cryptococcal meningitis. The mechanism of hearing loss in patients with cryptococcal meningitis is different from that in bacterial meningitis.

An immune-competent man with cryptococcal meningitis presented with sudden onset, bilateral, severe to profound sensorineural hearing loss and vestibular dysfunction. He was initially evaluated for cochlear implantation. However, he had a significant recovery; he no longer required surgery and was able to cope without a hearing aid.

Typically, cochlear implantation is performed with some urgency in patients with hearing loss post-bacterial meningitis, because of the risk of labyrinthitis ossificans. However, this process has not been described in patients with cryptococcal meningitis. Furthermore, patients with hearing loss associated with cryptococcal meningitis have shown varying degrees of reversibility. In this case report, hearing loss from cryptococcal meningitis is compared with that from bacterial meningitis, and the need for cochlear implantation in patients with cryptococcal meningitis is discussed.

To evaluate the prevalence of variations in the anatomical route of the spinal accessory nerve from the base of the skull to the point where it enters the trapezius muscle. A case report is used to demonstrate an example of a rare but clinically important anatomical variant of this nerve.

An independent review of the literature using Medline, PubMed and Q Read databases was performed using combinations of terms including ‘spinal accessory nerve’, ‘anatomy’, ‘surgical anatomy’, ‘anatomical variant’, ‘cranial nerve XI’ and ‘shoulder syndrome’.

Our report demonstrates marked variation in spinal accessory nerve anatomy. At the point of crossing over the internal jugular vein, the spinal accessory nerve passes most commonly laterally (anterior) to the internal jugular vein. The reported incidence of this lateral relationship varies from 67 to 96 per cent. The nerve can also pierce the internal jugular vein, as demonstrated in our case study, with incidence ranging from 0.48 to 3.3 per cent.

Anatomical variations of the spinal accessory nerve are not uncommon, and it is important for the surgeon to be aware of such variations when undertaking surgery in both the anterior and posterior triangles of the neck.

This study evaluated whether primary tumour characteristics are associated with specific features of metastatic lymph nodes in papillary thyroid carcinoma patients.

A retrospective review of 411 patients with pathologically diagnosed cervical lymph node metastasis was conducted.

A metastatic lymph node focus size of at least 2 mm was independently associated with a primary tumour size of at least 1 cm (hazard ratio 1.962) and with male sex (hazard ratio 1.947). A number of at least five lymph node metastases was independently associated with a primary tumour size of at least 1 cm (hazard ratio 2.863), extrathyroidal extension (hazard ratio 1.737) and male sex (hazard ratio 1.689). Extranodal extension was independently associated with a primary tumour size of at least 1 cm (hazard ratio 2.288), extrathyroidal extension (2.201) and male sex (hazard ratio 1.733).

Primary papillary thyroid carcinoma characteristics are related to the pathological features of lymph node metastases.

External approaches have been traditionally used for the complete excision of large retropharyngeal space lesions.

This paper describes a case of a large schwannoma of the retropharyngeal space excised transorally with the use of a robotic system. This lesion measured 2.7 × 1.2 cm in axial dimensions and over 5.8 cm in craniocaudal length. The lesion was delivered en bloc with an intact capsule. No peri- or post-operative complications were encountered. The procedure allowed quick resumption of an oral diet and a return to normal activity for the patient.

This is, to our knowledge, the first report of this technique used in the excision of a large retropharyngeal space mass.

Azelastine nasal spray is a topical antihistaminic drug for the symptomatic treatment of allergic rhinitis. This study aimed to investigate the effects of azelastine on nasal and nasopharyngeal microflora.

Swab samples from 25 patients prescribed azelastine nasal spray monotherapy were collected just before treatment and after 1 month of treatment. After incubation of inoculates, the number of bacteria present in cultures was measured (in colony-forming units per millilitre).

Evaluation of the number of microflora revealed increased bacterial reproduction after treatment, but this difference was not statistically significant. The use of azelastine nasal spray decreased the reproduction of three potentially pathogenic bacteria; however, it did not affect the reproduction of other potentially pathogenic bacteria.

The use of azelastine nasal spray for one month did not have a statistically significant effect on the numbers of nasal and nasopharyngeal microflora; it is therefore safe from a microbiological viewpoint.