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Background: Retropharyngeal haematomas are most commonly associated with trauma and anti-coagulant use. This paper describes the first reported case of a spontaneous retropharyngeal haematoma suspected to be due to indomethacin use., Case Report: It is proposed that the combination of indomethacin affecting platelet aggregation, alongside the patient coughing, may have led to this retropharyngeal haematoma., Conclusion: The complexities of management are discussed and the current literature reviewed. In the absence of airway compromise or a rapidly enlarging haematoma, patients can be managed conservatively with observation and close discussion with the haematology department. Follow-up imaging is not necessary if the patient's symptoms settle; however, any increase in parathyroid hormone levels must be investigated to exclude a parathyroid adenoma.

Rhabdomyosarcoma is a rare malignant tumour of striated muscle accounting for 3% of all primary soft tissue tumours of the middle ear cavity. We describe a unique case of a rhabdomyosarcoma of the middle ear cavity in a four-year-old boy, presenting as an otherwise asymptomatic ipsilateral Horner's syndrome. This case involved tumour erosion through the tensor tympani semicanal, accessing the carotid canal and the sympathetic plexus running through it. This child was treated successfully with chemotherapy and proton beam therapy, and remains disease free at six years of follow-up. This case highlights the importance of investigating patients with non-resolving ear infections, polyps or granulation tissue.

Introduction: A retrospective evaluation of pre- and post-operative audiometric data at a single large UK cochlear implant centre over 25 years was undertaken., Methods: Analysis of pre-operative hearing levels showed that there was a modest but significant reduction in average pre-operative hearing thresholds among patients referred between 1990 and 2015, particularly in the low frequencies., Outcomes: The proportion of those referred who would meet widely-accepted candidacy criteria for electro-acoustic stimulation (EAS) grew significantly over time but in the period 2011-2015 just 9% of those referred had sufficient residual hearing for EAS. On average, implant recipients lost 20 dB hearing at frequencies ≤1000 Hz as a result of the surgery., Conclusions: The findings suggest that hearing preservation is now widely achievable, and that both candidacy criteria and referrer education should take into account potential EAS benefit.

Streptococcus pneumoniaeis one of the key pathogens responsible for otitis media (OM), the most common infection in children and the largest cause of childhood antibiotic prescription. Novel therapeutic strategies that reduce the overall antibiotic consumption due to OM are required because, although widespread pneumococcal conjugate immunization has controlled invasive pneumococcal disease, overall OM incidence has not decreased. Biofilm formation represents an important phenotype contributing to the antibiotic tolerance and persistence ofS. pneumoniaein chronic or recurrent OM. We investigated the treatment of pneumococcal biofilms with nitric oxide (NO), an endogenous signaling molecule and therapeutic agent that has been demonstrated to trigger biofilm dispersal in other bacterial species. We hypothesized that addition of low concentrations of NO to pneumococcal biofilms would improve antibiotic efficacy and that higher concentrations exert direct antibacterial effects. Unlike in many other bacterial species, low concentrations of NO did not result inS. pneumoniaebiofilm dispersal. Instead, treatment of bothin vitrobiofilms andex vivoadenoid tissue samples (a reservoir forS. pneumoniaebiofilms) with low concentrations of NO enhanced pneumococcal killing when combined with amoxicillin-clavulanic acid, an antibiotic commonly used to treat chronic OM. Quantitative proteomic analysis using iTRAQ (isobaric tag for relative and absolute quantitation) identified 13 proteins that were differentially expressed following low-concentration NO treatment, 85% of which function in metabolism or translation. Treatment with low-concentration NO, therefore, appears to modulate pneumococcal metabolism and may represent a novel therapeutic approach to reduce antibiotic tolerance in pneumococcal biofilms., (Copyright © 2016, American Society for Microbiology. All Rights Reserved.)

Malignant external otitis (MEO) is a severe infection of the external auditory meatus caused by Pseudomonas aeruginosa. Classical features include unrelenting deep otalgia, otorrhoea and granulations in the floor of the ear canal. Treatment is generally protracted antibiotic therapy and monitoring of inflammatory markers; the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Traditionally computed tomography (CT) has been the imaging modality of choice. The authors present a case where magnetic resonance imaging (MRI) has been crucial in the diagnosis and follow up of a patient with MEO.

Objective: Subglottic cysts are a relatively rare, non-malignant cause of airway obstruction. In this study we reviewed the details of the patients who were treated for subglottic cysts in our department in order to evaluate the presentation and treatment of patients with this condition., Methods: We performed a retrospective case note analysis of 55 patients with subglottic cysts. Case notes were examined to determine the following details for each patient: date of birth, gestational age at birth, history and length of intubation, age at presentation, presenting symptoms, findings on endoscopy, treatment given for subglottic cysts, recurrence(s) of cysts after initial treatment, and follow up for a minimum of 6 months post diagnosis., Results: Fifty five patients were identified, 35 male, 20 female. Ninety four percent were born prematurely at 24-31 weeks gestation. All patients were intubated in the neonatal period. The median duration of intubation for all patients was 10 days (range 1-126). Fifty one patients underwent intervention for their subglottic cysts at their initial, diagnostic microlaryngoscopy and bronchoscopy (MLB), and recurrent cysts occurred in 22 cases. A total of 82 procedures for cyst removal were performed, using either the carbon dioxide laser or microinstruments. Subglottic stenosis was a commonly associated feature in our series of patients, being present in 38 patients. Eleven of the 14 patients who presented to our department with tracheostomies in situ were decannulated after removal of their subglottic cysts., Conclusions: This review of the largest series of patients with subglottic cysts reported to date, reinforces our view that such cysts are rare but potentially reversible causes of upper airway obstruction, and that they result from injury to the larynx as a result of endotracheal intubation. Treatment of the cysts will often be sufficient to correct the obstructed airway allowing successful extubation or decannulation of a tracheostomy. Patients who have had subglottic cysts treated should have access to long-term follow up as there is a tendency for these cysts to recur.

Cochlear endolymph is maintained at a potential of (+)80 mV by an active transport mechanism involving the stria vascularis (SV). This so-called endocochlear potential (EP) is integral to hair cell transduction. We compared the EP with changes in SV area and Na(+),K(+)-ATPase expression following a sensorineural hearing loss. Guinea pigs were deafened using kanamycin and a loop diuretic, and the EP was measured at two, 14, 56, 112 or 224 days following deafening. Auditory brainstem responses were used to confirm that each animal had a severe-profound hearing loss. There was a significant reduction in EP following two days of deafness (normal, 73.5 mV S.E.M.=2.4; deaf, 42.1 mV, S.E.M.=2.8; P<0.0001, t-test). In animals deafened for 14 days the EP had partially recovered (65.2 mV, S.E.M.=5.08), while animals deafened for longer periods exhibited a complete recovery (56 days 80.5 mV, S.E.M.=5.36; 112 days 75.7 mV, S.E.M.=2.71; 224 days 81.0 mV; S.E.M.=6.0). Despite this recovery, there was a systematic reduction in SV area with duration of deafness over the first 112 days of deafness. Significant reductions were localised to the basal turn in animals deafened for two days, but had extended to all turns in animals deafened for 112 days. While there was a significant reduction in strial area, the optical density of Na(+),K(+)-ATPase within the remaining SV was normal. Since the treated animals exhibited essentially a complete elimination of all hair cells, the total K(+) leakage current from the scala media would be expected to be significantly reduced. The large reduction in the extent of the SV after deafening suggests that a reduced strial volume is capable of maintaining a normal EP under conditions of reduced K(+) leakage current.

Objective: To review the mechanisms and nature of intracochlear damage associated with cochlear implant electrode array insertion, in particular, the various perimodiolar electrode designs. Make recommendations regarding surgical techniques for the Nucleus Contour electrode to ensure correct position and minimal insertion trauma., Background: The potential advantages of increased modiolar proximity of intracochlear multichannel electrode arrays are a reduction in stimulation thresholds, an increase in dynamic range and more localized neural excitation. This may improve speech perception and reduce power consumption. These advantages may be negated if increased intracochlear damage results from the method used to position the electrodes close to the modiolus., Method: A review of the University of Melbourne Department of Otolaryngology experience with temporal bone safety studies using the Nucleus standard straight electrode array and a variety of perimodiolar electrode array designs; comparison with temporal bone insertion studies from other centres and postmortem histopathology studies reported in the literature. Review of our initial clinical experience using the Nucleus Contour electrode array., Results: The nature of intracochlear damage resulting from electrode insertion trauma ranges from minor, localized, spiral ligament tear to diffuse organ of Corti disruption and osseous spiral lamina fracture. The type of damage depends on the mechanical characteristics of the electrode array, the stiffness, curvature and size of the electrode in relation to the scala, and the surgical technique. The narrow, flexible, straight arrays are the least traumatic. Pre-curved or stiffer arrays are associated with an incidence of basilar membrane perforation. The cochleostomy must be correctly sited in relation to the round window to ensure scala tympani insertion. A cochleostomy anterior to the round window rather than inferior may lead to scala media or scala vestibuli insertion., Conclusion: Proximity of electrodes to the modiolus can be achieved without intracochlear damage provided the electrode array is a free fit within the scala, of appropriate size and shape, and accurate scala tympani insertion is performed.

Snoring is a common problem, which may have widespread medical and social implications. This is particularly true in the setting of the armed forces where snoring may have significant effects in terms of personal performance, social interaction and security. This paper discusses the general management of snoring in the military environment and in particular the clinical effectiveness of one surgical procedure, uvulopalatopharyngoplasty. In this study, the procedure proves to be an effective surgical option in the management of snoring.

Tonsillectomy is one of the most common surgical procedures performed in children. Day case tonsillectomy is common in many parts of the USA but remains controversial in the UK. Day case tonsillectomy in children has been performed in a dedicated paediatric day care unit at the May day Hospital since 1994. The results for the years 1995-1997 were reviewed. In these years 928 true day case tonsillectomies were performed. Reactionary haemorrhage occurred in 0.97% (nine children) but only three children required a return to theatre. All bleeding occurred within the standard observation period. There were no deaths. The overall effective day case rate was 95.7%, only 31 children needing unplanned admission, mainly for postoperative vomiting. The results suggest that day case tonsillectomy can be safely and successfully performed, with a dedicated paediatric day case unit and a favourable population geography.

With the increasing role of evidence-based medicine we, as ENT surgeons, are being asked more and more to justify the practice of grommet insertion in children with glue ear. The audiological improvement which follows this operation is often only moderate at best. When judged solely in terms of hearing improvement, one may miss the often dramatic all-round improvement in a child which the parents frequently report to us postoperatively. We set out to confirm this clinical observation by using a retrospective questionnaire, seeking parental opinion after their children had undergone grommet insertion. We found a wide range of reported benefits as a result of grommet insertion; these include an improvement in hearing (92.1%), a reduced frequency of ear infections (74.1%), a reduction in postoperative GP visits (87%), less time missed from school (70.7%), as well as a variety of improvements in children's speech, education and general behaviour. Overall, we found that 96.7% of parents were satisfied that the decision to insert grommets in their child was correct. We feel that these non-audiological factors should be taken into account when judging the potential benefit to a child, or population of children, from grommet insertion.

Two cases of metastatic carcinoma of the temporal bone, that simulated glomus tumours on thorough preoperative evaluation are described. Although rare, metastatic spread to this area is recognized, but presentation in this way is unique.

Spontaneous massive haemorrhage from a parathyroid adenoma is rare. It can cause extensive cervical ecchymosis as well as compression of structures within the neck. We present a case, discuss the diagnostic features and review the literature.

Vestibular nerve dysfunction as the major neuro-otological symptom in one of the osteopetrosis group of bone disorders is unusual. We describe a patient with Engelmann's disease who presented in this manner and who benefited from an eighth nerve decompression procedure. Surgical decompression of the internal auditory meatus to relieve vertigo has to our knowledge not been previously reported in this condition.

A prospective study was undertaken to compare the efficacy of Merocel nasal tampons to BIPP (Bismuth Subnitrate and Iodoform Paste) impregnated ribbon gauze in the control of acute epistaxis requiring hospital admission. A total of 50 patients presenting with severe epistaxis was treated with either merocel nasal tampons, or BIPP. The groups did not differ significantly in terms of age, sex distribution, aetiology or severity of the bleed. There was no significant difference in efficacy or patient tolerance of either treatment. It was concluded that Merocel nasal tampons should be considered effective in the first line treatment of severe epistaxis uncontrolled by simple measures. Their ease of insertion makes them suitable for use in the accident and emergency department or in general practice.

Polyarteritis nodosa (PAN) is an uncommon but well documented cause of subarachnoid haemorrhage (SAH). We report a case of SAH in a patient with PAN causing death indirectly from the effects of resultant cardiovascular changes upon other manifestations of PAN. Clinicians should be aware of the systemic effects of SAH in patients with known vasculitides.

Haemangiopericytoma is a rare, soft tissue, tumour with unpredictable biological behaviour. A case of haemangiopericytoma of the parotid salivary gland is reported. The clinical, surgical and histological features are described.

Two long-term wear behavior studies used in part of the process of selecting the best materials for a new all-metal orthopaedic spinal implant are presented. The relative and absolute wear volume rates of candidate metals were investigated through simulation of two bearing regions of an intervertebral disc prosthesis. It was determined gravimetrically that hot isostatically pressed Co-Cr-Mo alloy provided the lowest Co-Cr-Mo alloy wear debris generation. It had an average wear volume rate of 0.093 mm3/million cycles from a spring-in-pocket simulation and 0.126 mm3/million cycles from a hinge (pin-in-slot) simulation. The estimated total wear volume of a hot isostatically pressed intervertebral disc prosthesis with titanium-6%Al-4%V alloy springs was 2.9 mm3/million cycles.

This article presents criteria for the design of a lumbar intervertebral disc prosthesis that take into consideration issues of endurance, materials behavior, geometry, kinetics, motion constraints, fixation to bone, and safety. The criteria and design philosophies discussed are generally applicable in the synthesis of any new implant system. Specifications of the design of a disc prosthesis are presented along with an evaluation of the design based on some of the preliminary test data.