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An 11-year old child presented with a sore throat due to diphtheria, and died in hospital two days later from the disease. Only four cases of diphtheria have been reported in South Africa since 2000, and none since 2005. The clinical presentation, differential diagnosis, diagnosis, and management of diphtheria are discussed. Despite an established immunisation programme, isolated cases of diphtheria still occur in South Africa, and with international travel, should form part of the differential diagnosis of sore throats anywhere, as treatment has to be instituted promptly to ensure a favourable outcome.

We present a case of a parapharyngeal space myxoid liposarcoma. This case highlights the importance of wide surgical resection margins, and the difficult histological diagnosis.

Background Cartilage invasion adversely affects the outcome of laryngeal carcinoma treated with radiotherapy. The UICC and American Joint Committee on Cancer (AJCC) classify laryngeal carcinoma with cartilage invasion as T4 or stage IV. Methods This study examines the prognostic significance of cartilage involvement in T3,4 N0,1 glottic carcinoma treated with total laryngectomy. Patients with tumor extension to pharynx, tongue, and thyroid gland, extracapsular spread, positive resection margins, and less than 2 years' follow-up were excluded. Results Sixty-seven pT3 (cartilage free of tumor) and 37 pT4 (cartilage invaded by tumor) cases were studied. The difference between the pT3 and pT4 groups in terms of local or regional recurrence, distant metastasis, and determinate survival was not significant. Conclusions The results of this study question the use of cartilage invasion as a staging parameter for surgically treated laryngeal carcinoma. However, further studies with larger sample sizes are required to fully elucidate the prognostic significance, if any, of cartilage invasion in surgically treated cancer of the larynx. © 1998 John Wiley & Sons, Inc. Head Neck 20:189–192, 1998.

Intranasal endoscopic excision of a juvenile nasopharyngeal angiofibroma (JNA) was performed in a 13 year old white male. The patient remains disease-free 24 months after the operation. Although endoscopic surgical techniques have been applied to the therapy of some benign nasal tumors, such as inverting papilloma, endoscopic resection of a documented JNA has not been previously reported. This technique is reserved for tumors which are limited to the nasal cavity and paranasal sinuses with minimal extension into the pterygopalatine fossa.

Background A review of 16 juvenile nasopharyngeal angiofibromas, managed at the University of Pittsburgh, is presented. Methods A retrospective chart review was done. Surgical approaches and factors affecting recurrence are analyzed. Results Endoscopic transnasal, transpalatal, medial maxillectomy, facial translocation, and infratemporal fossa approaches, with or without craniotomy, were employed. The 37.5% recurrence rate reflects the advanced stage of the tumors. A major risk factor for recurrence was tumor involvement of the cranial base. Conclusions The surgical approach should be selected according to tumor location and effectiveness of embolization. In young patients, the approach should minimize the potential for facial growth retardation. Tumors confined to the nasopharynx, nasal cavity, and paranasal sinuses may be removed endoscopically. Medial maxillectomy is recommended for tumors that extend to the medial infratemporal fossa or medial cavernous sinus. Significant involvement of the infratemporal fossa, cavernous sinus, or middle cranial fossa requires infratemporal fossa or transfacial approaches.© 1997 John Wiley & Sons, Inc. Head Neck19: 391–399, 1997

Objective: To review the surgical management of neurilemomas of the parapharyngeal space (PPS). Design: Retrospective survey of the clinical presentation, radiological features, surgical approaches, surgical findings, and postoperative neurological sequelae of neurilemomas of the PPS. Setting: Academic tertiary care head and neck referral center. Patients: Fourteen patients with neurilemomas of the PPS; 12 were in the poststyloid compartment. Interventions: Preoperative evaluation with computed tomography and/or magnetic resonance imaging with or without angiography. Surgical resection was performed through a transcervical approach. Main Outcome Measures: Radiological features, adequacy of surgical approach, and neurological sequelae of surgery. Results: Radiological studies could distinguish prestyloid from poststyloid tumors and, with poststyloid tumors, can usually differentiate between glomus tumor and neurilemoma. The transcervical approach permitted adequate surgical access. Five of the tumors in the poststyloid space were neurilomomas originating from the sympathetic nervous system, and all 5 patients with these tumors developed Horner syndrome postoperatively. Conclusions: Computed tomographic and/or magnetic resonance studies should be routinely obtained to evaluate tumors of the PPS, but angiography is indicated only in selected cases. Both prestyloid and poststyloid neurilemomas can be resected through a transcervical approach. Resection of neurilemomas has an attendant risk for neurological dysfunction. Arch Otolaryngol Head Neck Surg. 1997;123:622-626

Item does not contain fulltext Although uncommon, cancer of an unknown primary (CUP) metastatic to cervical lymph nodes poses a range of dilemmas relating to optimal treatment. The ideal resolution would be a properly designed prospective randomized trial, but it is unlikely that this will ever be conducted in this group of patients. Accordingly, knowledge gained from retrospective studies and experience from treating patients with known head and neck primary tumors form the basis of therapeutic strategies in CUP. This review provides a critical appraisal of various treatment approaches described in the literature. Emerging treatment options for CUP with metastases to cervical lymph nodes are discussed in view of recent innovations in the field of head and neck oncology and suitable therapeutic strategies for particular clinical scenarios are presented. For pN1 or cN1 disease without extracapsular extension (ECE), selective neck dissection or radiotherapy offer high rates of regional control. For more advanced neck disease, intensive combined treatment is required, either a combination of neck dissection and radiotherapy, or initial (chemo)radiotherapy followed by neck dissection if a complete response is not recorded on imaging. Each of these approaches seems to be equally effective. Use of extensive bilateral neck/mucosal irradiation must be weighed against toxicity, availability of close follow-up with elective neck imaging and guided fine-needle aspiration biopsy (FNAB) when appropriate, the human papillomavirus (HPV) status of the tumor, and particularly against the distribution pattern (oropharynx in the majority of cases) and the emergence rate of hidden primary lesions (

Objective:To report two cases of laryngeal plasmablastic lymphoma, a rare and relatively recently described form of non-Hodgkin's lymphoma. It has not previously been described in the larynx, nor associated with upper airway obstruction.Case reports:We describe the clinicopathological features of two such cases in human immunodeficiency virus positive patients, and we discuss their unusual presentations and diagnostic features.Conclusion:When evaluating a laryngeal tumour, plasmablastic lymphoma and other non-Hodgkin's lymphomata should be considered as differential diagnoses, particularly in the setting of a high prevalence of human immunodeficiency virus infection. Biopsy with detailed histopathological and immunohistochemical evaluation is recommended to ensure correct diagnosis and optimal management.

Item does not contain fulltext Perineural invasion (PNI) occurs in 2% to 6% of cutaneous head and neck basal and squamous cell carcinomas (SCCs) and is associated with mid-face location, recurrent tumors, high histologic grade, and increasing tumor size. Patients may be asymptomatic with PNI appreciated on pathologic examination of the surgical specimen (microscopic), or may present with cranial nerve (CN) deficits (clinical). The V and VII CNs are most commonly involved. Magnetic resonance imaging (MRI) may be obtained to detect and define the extent of PNI; computed tomography (CT) or ultrasound-guided fine needle aspiration cytology (UGFNAC) may assist with detecting or excluding regional lymph node metastases. Patients with apparently resectable cancers undergo surgery, usually followed by postoperative radiotherapy (RT). Patients with unresectable cancers are treated with definitive RT. Moreover, RT may be considered if significant functional or cosmetic impairment is expected after surgical treatment. The 5-year outcomes after treatment for clinically unsuspected microscopic compared with clinical PNI are: local control, 80% and 55%; cause-specific survival, 75% and 65%; and overall survival, 55% and 50%, respectively. The incidence of grade >/= 3 complications is higher after treatment for clinical PNI versus microscopic PNI; approximately 35% compared with 15%, respectively. Proton beam RT may be used to reduce the risk of late complications by reducing RT dose to the visual apparatus and central nervous system (CNS).

Introduction 295Resuscitation 295Airway control and cervical spine protection 295Assessment of breathing 296Adequacy of circulation 296Assessment of disability 296Exposure of patient 296Placement of tubes and essential x-rays 296Reassessment of patient 296Mandatory operation versus mandatory imaging versusselective physical examinations and intervention 297Clinical evaluation 297Diagnostic investigations 298Gunshot wounds versus knife wounds 299Retained sharp objects 300Specific injuries 300Key evidence 302Key learning points 302References 303There are 4 degrees of intra-operative hemorrhage:1. Why did I get involved in this operation? 2. Why did I become a surgeon? 3. Why did I study to become a doctor? 4. Why was I born?

Background. Ototoxicity following aminoglycoside treatment for multidrug-resistant tuberculosis (MDR-TB), is a significant problem. This study documents the incidence of ototoxicity in HIV-positive and HIV-negative patients with MDR-TB and presents clinical guidelines relating to ototoxicity.Methods. A prospective cohort study of 153 MDR-TB patients with normal hearing and middle ear status at baseline controlling for 6 mitochondrial mutations associated with aminoglycoside-related ototoxicity, at Brooklyn Chest Hospital in Cape Town. Pure tone audiometry was performed monthly for 3 months to determine hearing loss. HIV status was recorded, as was the presence of 6 mutations in the MT-RNR1 gene.Results. Fifty-seven per cent developed high-frequency hearing loss. HIV-positive patients (70%) were more likely to develop hearing loss than HIV-negative patients (42%). Of 115 patients who were genetically screened, none had MT-RNR1 mutations.Conclusion. Ototoxic hearing loss is common in MDR-TB patients treated with aminoglycosides. HIV-positive patients are at increased risk of ototoxicity. Auditory monitoring and auditory rehabilitation should be an integral part of the package of care of MDR-TB patients.S Afr Med J 2012;102(6):363-366

Alfio Ferlito, MD, DLO, DPath, FRCSEd ad hominem, FRCS (Eng, Glasg, Ir) ad eundem, FDSRCS ad eundem, FHKCORL, FRCPath, FASCP, IFCAP, K. Thomas Robbins, MD, FRCSC, Jatin P. Shah, MD, PhD (Hon), MS, FRCSEd (Hon), FRACS (Hon), FDSRCS, Jesus E. Medina, MD, Carl E. Silver, MD, Shawkat Al-Tamimi, MD, Johannes J. Fagan, MBChB, FCS (SA) MMed, Vinidh Paleri, MS, FRCS (ORL-HNS), Robert P. Takes, MD, PhD, Carol R. Bradford, MD, Kenneth O. Devaney, MD, JD, FCAP, Sandro J. Stoeckli, MD, Randal S. Weber, MD, Patrick J. Bradley, MB, BCh, BAO, DCH, MBA, FRCS (Ed, Eng, Ir), FHKCORL, FRCSLT (Hon), FRACS (Hon), Carlos Suarez, MD, PhD, C. Rene Leemans, MD, PhD, H. Hakan Coskun, MD, Karen T. Pitman, MD, Ashok R. Shaha, MD, Remco de Bree, MD, PhD, Dana M. Hartl, MD, PhD, Missak Haigentz, Jr, MD, Juan P. Rodrigo, MD, PhD, Marc Hamoir, MD, Avi Khafif, MD, Johannes A. Langendijk, MD, PhD, Randall P. Owen, MD, MS, Alvaro Sanabria, MD, MSc, PhD, Primož Strojan, MD, PhD, Vincent Vander Poorten, MD, PhD, Jochen A. Werner, MD, Stanislaw Bien, MD, PhD, Julia A. Woolgar, FRCPath, PhD, Peter Zbaren, MD, Jan Betka, MD, PhD, FCMA, Benedikt J. Folz, MD, Eric M. Genden, MD, Yoav P. Talmi, MD, Marshall Strome, MD, MS, Jesus Herranz Gonzalez Botas, MD, Jan Olofsson, MD, Luiz P. Kowalski, MD, PhD, Jon D. Holmes, DMD, MD, Yasuo Hisa, MD, PhD, Alessandra Rinaldo, MD, FRCSEd ad hominem, FRCS (Eng, Ir) ad eundem, FRCSGlasg

Background Tracheoesophageal fistula speech may be complicated by granulation tissue around the puncture site. Treatment includes antibiotics, antifungals, chemical or electrocautery, and surgical excision of the granulation tissue. Chemical cautery generally requires repeated treatment sessions. Methods We report our technique and results of CO2 laser ablation of granulation tissue at the tracheoesophageal puncture site performed as an outpatient office procedure. Results Seven of 9 patients (78%) were cured with a single treatment. The prosthesis was replaced immediately after laser ablation of granulation tissue. Of the remaining 2 patients, 1 had a recurrence a year later, requiring repeated laser. The second patient had a large mass requiring 4 laser ablations. There were no complications. Conclusions CO2 laser has the following advantages compared with other methods of treating stomal granulation tissue: office procedure; 78% cured with single treatment; and the extent of tissue necrosis is predictable. © 2000 John Wiley & Sons, Inc. Head Neck 22: 714–716, 2000., 2000.

We report three cases of hydatid disease of the skull base and the treatment thereof. The first involved the anterior cranial fossa and paranasal sinuses. The second was located in the infratemporal fossa. The last involved the temporal bone and posterior cranial fossa. Hydatid disease is endemic in many parts of the world where livestock farming is practiced and is highly endemic in sub-Saharan Africa. Although hydatid disease of the head and neck is rare, it should be considered in the differential diagnosis of cystic disease in the head and neck region. Of the three forms of hydatid disease, Echinococcus granulosis is most common and gives rise to cystic hydatid disease. Most hydatid cysts are “silent,” but become clinically apparent because of their mass effects, when they rupture, or if they become superinfected. Computed tomography scanning and magnetic resonance imaging are the best diagnostic tools. Hydatid disease can be successfully treated by a combination of surgery and chemotherapy.

Objective:The aim of the study was to determine the effectiveness of alcohol sclerotherapy in patients with human immunodeficiency virus related salivary gland disease.Study design:Prospective study investigating the effectiveness of alcohol as a sclerosing agent.Setting:Tertiary referral hospital.Patients:Eleven human immunodeficiency virus positive patients with benign lymphoepithelial cysts were included in the study, from July 2005 to September 2006.Interventions:Alcohol sclerotherapy was performed under local anaesthesia, with alcohol infiltrated into the benign lymphoepithelial cysts.Results:Alcohol injection sclerotherapy proved to be an effective, simple, cheap, ambulatory procedure for patients who did not qualify for antiretroviral treatment.

Total glossectomy (with or without total laryngectomy) followed by postoperative radiotherapy remains the principal treatment method for advanced base of tongue carcinoma. The procedure remains controversial owing to poor cure rates and the inevitable functional deficits associated with it. However, even though total glossectomy is a major surgical procedure that impacts on speech, deglutition and quality of life, it may offer patients the best chance of cure in many centres, especially in the developing world.We did a retrospective chart review of all patients at Groote Schuur Hospital, Cape Town, who had undergone total glossectomy, with or without total laryngectomy, for stage IV squamous cell carcinoma (SCC) of the tongue between 1998 and 2004.Eight patients had a total glossectomy performed during the study period. At 2, 3 and 5 years 63%, 38% and 25% of patients respectively were alive without disease. No patient required permanent nasogastric or gastrostomy feeding, and all returned to a full oral diet. Three of 5 patients who had laryngeal preservation and could be assessed for speech had intelligible speech. All but 1 patient (88%) reported pain relief following surgical excision. Perineural invasion was present in 75%, and 38% had positive resection margins. Five patients had recurrence, 2 cervical, 1 local, and 2 local and cervical.Advanced SCC of the tongue is a devastating disease causing severe pain and disorders of speech and swallowing. Total glossectomy (with or without total laryngectomy) and postoperative radiotherapy is a reasonable treatment option, particularly in the developing world setting. It has cure rates superior to primary radiotherapy, and provides motivated patients with excellent pain relief and a reasonable quality of life.

The goal of treatment for supraglottic cancer is to achieve cure and to preserve laryngeal function. Organ preservation strategies include both endoscopic and open surgical approaches as well as radiation and chemotherapy. The challenge is to select the correct modalities for each patient. Endoscopic procedures should be limited to tumors that can be completely visualized during diagnostic microlaryngoscopy. If complete resection can be achieved, the oncologic results of transoral laser surgery appear to be comparable to those of classic supraglottic laryngectomy. In addition, functional results of transoral laser resection are superior to those of the conventional open approach, in terms of the time required to restore swallowing, tracheotomy rate, incidence of pharyngocutaneous fistulae, and shorter hospital stay. The management of the neck remains of paramount importance, as survival of patients with supraglottic cancer depends more on cervical metastasis than on the primary tumor. Most authors advocate bilateral elective neck dissection. However, in selected cases (T1,T2 clinically negative [N0] lateral supraglottic cancers), ipsilateral selective neck dissection could be performed without compromising survival. The authors conclude that with careful selection of patients, laser supraglottic laryngectomy is a suitable, and often the preferred, treatment option for supraglottic cancer. © 2008 Wiley Periodicals, Inc. Head Neck, 2008

Introduction: The history of voice rehabilitation following laryngectomy is as long as the history of laryngectomy itself. The multitude of methods which have been employed to reduce the disability associated with the loss of the larynx, illustrate the difficulty of finding an optimal method of reestablishing verbal communication while preserving the ability to breathe and swallow. Material and Methods: The world literature was reviewed using various Internet and medical search engines and library facilities. Landmark articles were identified and summarized. Results: A coherent history of voice rehabilitation following laryngectomy was constructed. Discussion: The methods employed to reestablish voice after extirpation of the larynx may be grouped into the categories of: esophageal speech, surgical methods of creating competent tracheo-pharyngeal shunts to create lung powered voice with and without the use of prosthetic devices to prevent aspiration, “near-total” resection of the larynx with dynamic phonatory shunt, and the use of external pneumatic or electrical devices to create sound which is then transmitted through the oral cavity and pharynx. Conclusion: For the past two decades, simple shunt devices inserted either primarily, at the time of laryngectomy, or later as a secondary procedure, have mainly supplanted the other methods of voice rehabilitation, with the exception of an occasional patient who has acquired good esophageal speech, or for whom external devices may be the only practical method of voice production.

Several techniques have been developed to reconstruct oral and pharyngeal defects following surgery, in order to restore function and cosmesis. These are primary closure, skin grafts, local transposition of skin, mucosa and/or muscle, regional flaps and free vascularized flaps. Because of the 'bulky', pedicled nature and problems with the donor area of locoregional flaps, and consequently frequently unsatisfactory functional results, free vascularized flaps have gained popularity during the last decade. The authors review the current options available to give physicians, who are not experienced in the field of reconstruction in the head and neck, an impression of the range of techniques available for reconstruction of oral and pharyngeal defects following tumor resection. For reconstruction of oral cavity and pharyngeal defects, fasciocutaneous (e.g. radial forearm and anterolateral thigh flaps) and myocutaneous free flaps (e.g. rectus abdominis and latissimus dorsi) have proven to be very reliable. Free vascularized osteocutaneous flaps (e.g. fibula and iliac crest) permit reconstructive options for bony defects of the mandible or maxilla that can be adapted to a variety of defects. Depending on the site, size and involved tissues of the surgical defect and patient factors, a variety of reconstructive options are available. For both soft tissue and bony defects of the upper aerodigestive tract, microvascular free flaps provide good functional outcomes.

The spectrum of parotid disease in southern Africa has not previously been reported.A review of all parotidectomies performed by a single surgeon over a period of 10 years (1994 - 2004) in Cape Town, South Africa, is presented. Data were collected from a retrospective chart review.One hundred and ninety-nine parotidectomies were performed and 196 pathology reports were reviewed. Pleomorphic adenoma was the most common benign tumour and metastatic cutaneous squamous cell carcinoma (SCC) was the most common malignancy. Warthin's tumour had an equal gender distribution. Forty-five per cent of parotid tumours in males were malignant. The sensitivity, specificity and accuracy of fine-needle aspiration cytology (FNAC) in diagnosing malignancy were 73%, 98% and 94% respectively.In South African males almost half of parotid tumours are malignant. Warthin's tumours are less common in Africa than in the West, and did not show a male preponderance. FNAC is a highly reliable method of excluding malignancy.

There is continued controversy over the extent of parotidectomy required for removal of a benign pleomorphic adenoma from the parotid gland. Currently, consensus exists that the integrity of the facial nerve must be preserved when the tumour is totally removed.As a result of experience gained in the first half of the twentieth century, it was recommended that superficial parotidectomy with facial nerve dissection should be the minimal biopsy for pleomorphic adenoma. Since that time, however, research has indicated that partial parotidectomy or extracapsular dissection of benign pleomorphic adenoma can be accomplished with preservation of the facial nerve without an increase in tumour recurrence. Partial parotidectomy or extracapsular dissection results in impaired cosmetic results and a lower incidence of Frey's syndrome, and thus may be the preferred approach when undertaken by experienced surgeons.

The aims of the study were: (i) to determine the necessity for diagnostic tonsillectomy in children with asymmetrically enlarged tonsils; (ii) to determine the accuracy of clinical assessment of tonsillar asymmetry; and (iii) to determine how to manage children with clinical tonsillar asymmetry in a developing-world practice.A prospective study was carried out at Red Cross War Memorial Children's Hospital in Cape Town, over an 8-month period. All children undergoing tonsillectomy or adenotonsillectomy had a clinical assessment of tonsil symmetry done, and all tonsil and adenoid specimens were examined histologically. The maximum diameter and volume of the resected tonsils were measured. A comparison was done of true tonsil asymmetry in patients with asymmetrical tonsils and a subgroup of matched controls with symmetrical tonsils.A total of 344 tonsils were analysed (172 patients). The 13 patients (7.6%) diagnosed as having clinically asymmetrically enlarged tonsils had no significant pathological diagnosis. In the patients with symmetrical tonsils there were 2 abnormal pathological findings (tuberculosis of the adenoids and T-cell lymphoma of the tonsils and adenoids). In the clinically asymmetrical tonsil group, true tonsillar asymmetry was 3 mm (maximum diameter), and 2.2 cm(3) (volume), compared with 1.9 mm and 1.5 cm(3) in the symmetrical tonsil group. When patients with clinical tonsillar asymmetry and symmetry were compared, the difference in maximum diameter (p = 0.62) and volume (p = 0.73) was not significantly different.Clinical tonsillar asymmetry is usually apparent rather than real. The incidence of significant pathology in children with asymptomatic, asymmetrical tonsils is low. Diagnostic tonsillectomy is indicated in children with asymmetrically enlarged tonsils associated with constitutional symptoms, cervical lymphadenopathy, rapid tonsil enlargement or significant tonsillar asymmetry.

The thyroglossal duct cyst [TDC, or thyroglossal tract remnant (TTR)] is a well recognized developmental abnormality which arises in some 7% of the population. As a consequence, it represents the most common type of developmental cyst encountered in the neck region. It typically presents as a mobile, painless mass in the anterior midline of the neck, usually in close proximity to the hyoid bone. Less often, TDCs may present with signs and symptoms of secondary infection, or with evidence of a fistula. While TDCs are most often diagnosed in the pediatric age group, a substantial minority of patients with TDCs are over 20 years of age at the time of diagnosis. The standard surgical approach to TDC, encompassing removal of the mid-portion of the hyoid bone in continuity with the TDC and excision of a core of tissue between the hyoid bone and the foramen cecum, dates back to the late 19th and early 20th centuries and is often referred to as Sistrunk's operation. Malignancy is rarely encountered in TDCs; when such rare tumors do develop (in the order of 1% or so of patients with TDCs), they usually take the form of either papillary carcinoma of thyroid origin, or squamous carcinoma.

Background: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.Materials and methods: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.Results: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.Conclusions:The buccinator myomycosal flap is a dependable flap with good functional outcome and low morbidity.

The history of the surgical treatment of cervical lymph node metastases began in the 19th century, and, unfortunately, the initial attempts at surgical treatment of neck metastases were disastrous. Although some European surgeons reported few cases of radical en bloc dissection, the first successful surgical procedure was performed and described in detail by Franciszek Jawdyński, a Polish surgeon, in 1888. George Washington Crile popularized and illustrated radical en bloc neck dissection in the early 20th century.

Squamous cell carcinoma has rarely been reported in black African people, with only 11 cases reported in the world literature to date. We report on 2 further cases, the first to be reported in southern Africa, of squamous cell carcinoma in lesions of discoid lupus erythematosus

Neuroblastoma is the most common extra-cranial solid malignancy in children and the most common tumour occurring during infancy. This tumour arises from undifferentiated precursor cells of the sympathetic nervous system. The abdomen (65 per cent) is the most common site for these tumours, followed by the throat (15 per cent), pelvis (5 per cent) and cervical region (5 per cent).We report a case of primary retropharyngeal neuroblastoma in a three-week-old baby boy presenting with upper airway obstruction

There is a paucity of data on morbidity associated with long waiting lists for adult tonsillectomy. The aim of this study was to assess the morbidity associated with long waiting lists for adult tonsillectomy in a developing world setting. Of 350 patients on the waiting list at Groote Schuur Hospital for 18 months or more, only 55 were contactable. This low yield (15.7%) from the telephonic survey highlighted the difficulty of managing long waiting lists efficiently in a developing world setting. As only 1/55 patients on the waiting list had a complication (quinsy), it appears to be safe to delay tonsillectomy in adult patients. Only half of patients ultimately required tonsillectomy because of a natural reduction in the number of episodes of tonsillitis with time. In order to avoid unnecessary tonsillectomy we need to find better prognosticators to identify the subgroup of adult patients likely to have continued recurrent tonsillitis.

Most patients with squamous cancer of the head and neck treated at Groote Schuur Hospital are from a poor socio-economic background with a high prevalence of tuberculosis (TB), human immunodeficiency virus (HIV) and other infections that may cause cervical lymphadenopathy resulting in overstaging of the neck.A retrospective review of 186 patients requiring therapeutic and elective neck dissection was undertaken and the sensitivity and specificity of clinical and intra-operative staging of the neck determined.Results showed overall sensitivity of staging at 80.1 per cent. Specificity was 52.2 per cent. Staging of the N1, N2b and N2c necks had positive predictive values of 53.2, 65.8 and 68.2 per cent respectively. Occult nodal metastases were present in 32 per cent elective neck dissections (END)s. Specificity of intra-operative staging of the N0 neck was 33.3 per cent and sensitivity was 72.4 per cent.Conclusions were that our indications for elective neck dissection are appropriate. The high false positive rates for staging of the N1, N2b and N2c necks, necessitate a change in management strategy.

This random survey was to determine the flexible nasopharyngoscope disinfection practice employed by South African otolaryngologists and to establish whether a breach in the disinfection process exists. The study also aimed to identify organisms most likely to be transmitted via endoscopy and to propose a protocol for the disinfection of the flexible nasopharyngoscope.A questionnaire regarding disinfection techniques used for the flexible nasopharyngoscope was sent to 90 otolaryngologists in South Africa. All provinces were equally represented in the survey.Forty-five otolaryngologists out of a total of 90 participated in the study. Many of the otolaryngologists had no access to a flexible nasopharyngoscope and were therefore not included in the study. Fewer than 50 per cent of the 45 surgeons washed the instrument with soap/detergent and water after use. Only 42 per cent of surgeons used a FDA-approved disinfectant, 52 per cent of which immersed the scope for a shorter period than the recommended contact time. Of the 58 per cent using non-FDA-approved products, 33 per cent used only a 70 per cent Isopropyl alcohol wipe, without immersion of the scope in disinfectant solution. The remaining 25 per cent used non-FDA-approved disinfectants either by wiping or limited immersion of the scope. Of the 45 surgeons, 49 per cent used a different method of disinfection for high-risk patients.Strict guidelines have been proposed for the disinfection of this semi-critical device by the Association of Professionals for Infection Control (APIC) and the Centers for Disease Control (CDC). These guidelines are currently not being followed by many South African otolaryngologists. There is therefore a real risk of transmitting infectious diseases, especially tuberculosis, via endoscopy.

7. Weiss D, Koopmann M, Rudack C. Prevalence and impact on clinicopa-thological characteristics of human papillomavirus-16 DNA in cervicallymph node metastases of head and neck squamous cell carcinoma.Head Neck 2011;33:856–862.8. Armas GL, Su CY, Huang CC, Fang FM, Chen CM, Chien CY. Theimpact of virus in N3 node dissection for head and neck cancer. EurArch Otorhinolaryngol 2008;265:1379–1384.9. Barwad A, Sood S, Gupta N, Rajwanshi A, Panda N, Srinivasan R.Human papilloma virus associated head and neck cancer: a PCR basedstudy. Diagn Cytopathol 2011;Epub ahead of print.10. Hoffmann M, Gottschlich S, G€or €ogh T, et al. Human papillomaviruses inlymph node neck metastases of head and neck cancers. Acta Otolaryngol2005;125:415–421.11. Desai PC, Jaglal MV, Gopal P, et al. Human papillomavirus in metastaticsquamous carcinoma from unknown primaries in the head and neck: a ret-rospective 7 year study. Exp Mol Pathol 2009;87:94–98.12. Compton AM, Moore-Medlin T, Herman-Ferdinandez L, et al. Humanpapillomavirus in metastatic lymph nodes from unknown primary headand neck squamous cell carcinoma. Otolaryngol Head Neck Surg 2011;145:51–57.

Background. Developing countries have the world’s highest prevalence of hearing loss, and hearing screening programmes are scarce. Mobile devices such as smartphones have potential for audiometric testing.Objectives. To evaluate the uHear app using an Apple iPhone as a possible hearing screening tool in the developing world, and to determine accuracy of certain hearing thresholds that could prove useful in early detection of hearing loss for high-risk populations in resource-poor communities.Methods. This was a quasi-experimental study design. Participants recruited from the Otolaryngology Clinic, Groote Schuur Hospital, Cape Town, South Africa, completed a uHear test in three settings – waiting room (WR), quiet room (QR) and soundproof room (SR). Thresholds were compared with formal audiograms.Results. Twenty-five patients were tested (50 ears). The uHear test detected moderate or worse hearing loss (pure-tone average (PTA) >40 dB) accurately with a sensitivity of 100% in all three environments. Specificity was 88% (SR), 73% (QR) and 68% (WR). It was highly accurate in detecting high-frequency hearing loss (2 000, 4 000, 6 000 Hz) in the QR and SR with ‘good’ and ‘very good’ kappa values, showing statistical significance (p40 dB). It is highly sensitive for detecting threshold changes at high frequencies, making it reasonably well suited to detect presbycusis and ototoxic hearing loss from HIV, tuberculosis therapy and chemotherapy. Portability and ease of use make it appropriate to use in developing world communities that lack screening programmes.

In the Department of Otolaryngology at the University of Pittsburgh School of Medicine, cancer of the larynx is usually treated by primary surgery. Radiotherapy is used as adjuvant treatment in certain patients who have cancer that has adverse histologic features such as perineural, vascular, and/or cartilage invasion. With this approach, patients rarely develop local recurrence. Patient survival is therefore unlikely to be improved by changes to the management of the primary tumor. Survival may, however, be improved by reducing the incidence of recurrence in the neck, as well as distant. Hence, we have adopted an aggressive surgical approach to the cN+ as well as the NO neck. The theoretical basis for this aggressive surgical approach to the neck will be considered under the following headings: staging, regional control, distant metastasis, survival, choice of neck dissection, and the pathologically positive elective neck dissection.

This article discusses the following aspects of the management of the N+ neck: evolution of neck dissection; specificity of staging of the clinically N+ neck; limitations of neck dissection in patients with adverse histologic features; management of bilateral nodal metastases, fixed nodes, and nodes with involvement of skin, nerves or the carotid artery; retropharyngeal nodes; and salvage treatment of the N+ neck following prior irradiation. A summary of the author's own approach is then presented.

Objective To determine if perineural invasion (PNI) of small nerves affects the outcome of patients with squamous cell carcinoma (SCC) of the upper aerodigestive tract. Design Retrospective clinicopathological study of patients with at least 2 years of follow-up and with negative margins and no prior, synchronous, or metachronous SCC. Setting Academic otolaryngology department. Patients One hundred forty-two patients who had SCC of the oral cavity, oropharynx and hypopharynx, or larynx resected between 1981 and 1991. Intervention Surgery with or without adjuvant therapy. Main Outcome Measures Local recurrence was examined with respect to PNI, nerve diameter, and microvascular or microlymphatic invasion. Perineural invasion was correlated with lymph node metastasis, extracapsular spread, and survival. Results Perineural invasion of nerves less than 1 mm in diameter was present in 74 patients, lymphatic invasion in 53, and vascular invasion in 9. Perineural invasion was significantly associated with local recurrence (23% for PNI vs 9% for no PNI; P =.02), and disease-specific mortality (54% mortality for PNI vs 25% for no PNI; P P =.03). Perineural invasion was not associated with extracapsular spread ( P =.47). Microvascular invasion, lymphatic invasion, and nerve diameter were not significantly related to local recurrence. Conclusions Perineural invasion of small nerves is associated with an increased risk of local recurrence and cervical metastasis and is, independent of extracapsular spread, a predictor of survival for patients with SCC of the upper aerodigestive tract.

Background. Chronic otorrhoea is difficult to treat, with treatment in South Africa (SA) being protocol driven and generally initiated at the primary healthcare level. There is a lack of local studies that focus on the bacteriology and antimicrobial sensitivities of chronic otorrhoea, which underpins the management advice offered. Aims. To determine the microbiological profile and antimicrobial susceptibility of patients with chronic otorrhoea and the validity of the Department of Health’s (DoH) current guideline. Methods. We conducted a prospective study at Groote Schuur Hospital from 2005 to 2009. We included patients with chronic otorrhoea classified as either otitis media or otitis externa, according to our definitions. Pus swabs were taken, from which microorganisms were cultured and tested for antimicrobial susceptibility. Results. Of 79 patients with otorrhoea, 50 had otitis media, 21 had otitis externa and the condition was not determined in 8 patients. The most common organism isolated with otitis media was Proteus mirabilis (18/50; 36%) and with otitis externa, Pseudomonas aeruginosa (7/21; 33%). Otorrhoea had a different microbial spectrum compared with international reports, with methicillin-resistant Staphylococcus aureus infection in a single patient. The organisms isolated were susceptible mainly to fluoroquinolones (96%) and aminoglycosides (81%). Conclusion. Amoxicillin is a poor choice of antibiotic due to its low sensitivity, which calls into question the current DoH guideline for otorrhoea. Antimicrobial treatment protocols should be based on local data and be revisited from time to time. This study suggests that, should first-line treatment fail, an antibiotic with Gram-negative cover, e.g. a topical fluoroquinolone, should be considered.

Laryngeal papillomotasis recurred in 2 patients after 44 and 47 years of remission. The recurrence of papillomatosis after such lengthy periods of remission underscores the fact that, while surgical treatment of laryngeal papillomatosis may maintain the airway and voice, and in some cases control clinically overt disease, it does not address the subclinical mucosal human papillomavirus infection that may lead to recurrence many years after surgery. Arch Otolaryngol Head Neck Surg. 1996;122:942-944

Background. Concern exists about the quality of specialist training platforms at South African universities and teaching hospitals. Method. We conducted an audit of the quality of training at South African otolaryngology (ENT) training institutions from the perspective of the registrars. Results. Some institutions were deficient in terms of supervision, theatre time, access to teaching aids and research tools, and range of surgery, and do not provide the required training platforms for ENT specialist training. Five out of 8 institutions have produced

Ascaris lumbricoides has rarely been implicated in the causation of middle ear disease. An infant who developed acute suppurative otitis media while on antibiotics for an upper respiratory tract infection and who extruded an ascaris worm from the ear is presented. The otitis media subsequently resolved. Our understanding of the pathophysiology of ascariasis in the eustacian tube and middle ear is discussed.

We present the case of a patient with a transethmoidal penetrating injury to the contralateral orbital apex and optic nerve. Orbital apex fractures can be broadly classified as linear (not displaced), comminuted (with fragment displacement), and apex avulsion. 1 The neurovascular anatomy of the orbital apex is complex, and injuries involving this area, directly or indirectly, can have different clinical outcomes. Numerous syndromes have been described depending on the combination of clinical findings. Clinical symptoms and signs do not always correlate with the degree of trauma or radiological findings. The neurovascular structures could be severely traumatized without an orbital apex fracture being present.

A lipoma situated within the posterior wall of the nasopharynx is reported. Only three lipomas of the nasopharynx in adults have previously been reported. The value of CT scan and cytology in making the preoperative diagnosis of a lipoma at this location is discussed.

Objectives To determine the tracheoesophageal speech results in a Third World medical practice; to examine the impact of socioeconomic status, literacy, and proximity to specialist services on tracheoesophageal speech; to assess whether these factors should affect patient selection for fistula speech; and to determine guidelines for voice prosthesis selection. Design Retrospective analysis. Setting Groote Schuur Hospital, Cape Town, South Africa, which serves a Third World community. Patients Ninety-seven consecutive patients who underwent total laryngectomy between January 1, 1996, and October 1, 1998. Patients who undergo total laryngectomy routinely have a primary tracheoesophageal fistula created for speech. Main Outcome Measures Speech outcomes after total laryngectomy; tracheoesophageal speech in relation to social class, literacy, and proximity to specialist services; and experience with removable and indwelling valves. Results Fifty-nine (81%) of 73 patients acquired useful speech. Speech outcome was not affected by employment status or proximity to specialist services. Although speech was affected by literacy and housing, several illiterate shack dwellers acquired good speech. Average device life of removable prostheses was 16 weeks (>4 months in 35% [64/183]). Indwelling prostheses had an average life of 28 weeks. Conclusions Tracheoesophageal speech results in a Third World community equate with those in the Developed World. All patients who undergo laryngectomy and have adequate manual dexterity and cognitive function should be given a trial of fistula speech. Removable voice prostheses can successfully be used as indwelling prostheses.

The temporal bones of a 6-year-old boy with a cochlear implant for profound hearing loss associated with Mondini dysplasia were studied histopathologically. Despite having severe Mondini dysplasia, he was able to detect sound with the implant. On histological examination of the temporal bone, he had more than 10000 spiral ganglion cells. Histopathological changes in the inner ear associated with the cochlear implant were minimal. Patients with severe Mondini dysplasia and profound hearing loss may, therefore, benefit from cochlear implantation. In the contralateral ear, the patient had suppurative labyrinthitis and meningitis associated with chronic otitis media. Histopathological evidence of inflammatory necrosis of the round window membrane was consistent with suppurative labyrinthitis secondary to otitis media.