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Osteomata of the frontal and ethmoid sinuses have traditionally been surgically removed via external approaches. However, endoscopic techniques have increasingly been used for the surgical management of selected cases. Advances in visualization and instrumentation, as well as the excellent access provided by the Draf type 3 procedure, expanded the reach of endoscopes. We describe current limits of endoscopic approaches in the removal of osteomata from the frontal sinus and our algorithms for their management. We believe that the vast majority of frontal sinus osteomata can be managed endoscopically, and that only significant anterior or extreme infero-lateral extension constitute major limiting factors., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Gustatory rhinitis is characterized by watery, uni- or bilateral rhinorrhea occurring after ingestion of solid or liquid foods, most often hot and spicy. It usually begins within a few minutes of ingestion of the implicated food, and is not associated with pruritus, sneezing, nasal congestion or facial pain. It is considered to be a non-immunological reaction. Immunohistological and pharmacological observations suggest that this disease is most likely caused by stimulation of trigeminal sensory nerve endings located at the upper aerodigestive track. Recent evidence suggests that sensory nerve stimulations could be associated with a parasympathetic reflex and activation of cholinergic muscarinic receptors, sensitive to atropine. There are various types of gustatory rhinitis, including age-related, posttraumatic, postsurgical and associated with cranial nerve neuropathy. Avoidance of the implicated foods, is the first treatment option, but it is rarely sufficient. The intranasal topical administration of anticholinergic agents such as atropine, either prophylactically or therapeutically has been shown effective. Surgical therapy in the form of posterior nasal nerve resection or vidian nerve neurectomy is not recommended because of its short lasting result and frequent unpleasant side effects.

Over the last 20 years, there has been significant progress in our understanding of the pathophysiology of allergic rhinitis, including the discovery of new inflammatory mediators, the link between asthma and allergic rhinitis ('one airway-one disease' concept) and the introduction of novel therapeutic modalities. These new insights have been documented in the Allergic Rhinitis and its Impact on Asthma guidelines and have led to the creation of evidence-based management algorithms. We now understand the importance of a common strategy for treating allergic inflammation of the upper and lower airway as a way of improving outcome, reducing hospital admissions, providing better quality of life and perhaps, altering the natural course of the 'allergic march'. A therapeutic ladder is suggested: Whereas for mild intermittent allergic rhinitis, allergen avoidance should be the first line of treatment with subsequent addition of a second generation topical or oral antihistamine, nasal saline or cromoglycate, in cases of moderate to severe allergic rhinitis, a nasal steroid is the treatment of choice. If a patient with moderate/severe persistent allergic rhinitis fails to improve after 4 wk of adequate treatment, patient compliance or the diagnosis must be re-assessed. In such cases, when the diagnosis is in doubt, a careful clinical examination including nasal endoscopy is mandatory to assess for other potential causes of nasal obstruction. In children who suffer from concomitant allergic rhinitis and asthma, a management algorithm that addresses concurrently asthma and allergic rhinitis is vital, both from a theoretical and from a practical point of view: Parents overwhelmingly prefer a single strategy for the treatment of their child's upper and lower airway symptoms; however, the overall quality of life in children with severe asthma can be significantly improved if rhinitis is adequately addressed., (© 2009 John Wiley & Sons A/S.)

Introduction: The definition of severe recurrent throat infections is arbitrary, but recent criteria have defined severe tonsillitis as: five or more episodes of true tonsillitis a year; symptoms for at least 1 year; and episodes that are disabling and prevent normal functioning. Diagnosis of acute tonsillitis is clinical, and it can be difficult to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis, but more accurate tests take longer to deliver results. Bacteria are cultured from few people with tonsillitis. Other causes include infectious mononucleosis from Epstein-Barr virus infection, cytomegalovirus, toxoplasmosis, HIV, hepatitis A, and rubella., Methods and Outcomes: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of tonsillectomy in children and adults with acute recurrent or chronic throat infections? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA)., Results: We found 10 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions., Conclusions: In this systematic review we present information relating to the effectiveness and safety of the following interventions: cold-steel tonsillectomy and diathermy tonsillectomy.

The role of fungi in chronic rhinosinusitis (CRS) is not clear. Fungi can be detected in the nose and paranasal sinuses of virtually all CRS patients; however, they also appear to be present in healthy controls. Various theories attempt to explain the mechanisms by which fungi can exert an effect on sinus mucosa in susceptible individuals. Further studies are necessary to clarify the role of fungi in CRS, which fungal organisms (if any) are pathogenic, and what exactly characterizes the immunologic response to fungi that may result in the development of disease. However, in the absence of convincing immunologic data and evidence of clinical improvement of CRS after antifungal therapy, the case against the fungus remains unproven.

Introduction: There is no standard definition for thyroid glands extending below the thoracic inlet, and there are no clear guidelines for pre-operatively identifying those patients that may require an intrathoracic approach. We therefore reviewed the current literature in order to establish the current practices regarding the management of retrosternal goitres (RSGs), and propose a classification system to aid pre-operative planning for this important group of patients., Materials and Methods: A PubMed Medline search was conducted using the search terms 'retrosternal', 'substernal', 'intrathoracic', 'mediastinal', 'goitre' and 'goiter', resulting in 626 hits. Exclusion criteria reduced the number of papers to the 34 used for this review., Results: A total of 34 papers totaling 2426 patients were included. Eighty-four percent of patients operated on for RSG were achieved via a cervical approach, with the remainder also requiring manubriotomy (3.1%), full sternotomy (6.6%) or thoracotomy (4%). Tracheomalacia occurred in 1% of patients and Superior Vena Cava syndrome (SVC) in 3.2%. There was a clear and highly significant association between the extent and definition of RSG and reported complications, as well as the approach used, with the incidence of tracheomalacia, SVC and need for intrathoracic approach increasing more than 10-fold in cases of RSG reaching the aortic arch., Discussion: There is a clear need to establish a common standard in the definition and description of the extent of RSG. Using our findings, we propose a new, simple, 3-grade classification system of RSGs, based on their relation with the aortic arch and the right atrium.

Sleep nasendoscopy was conceived at the Royal National Throat, Nose and Ear Hospital, UK in 1991, and has remained fully implemented in patient selection for targeted treatment of the spectrum of sleep-disordered breathing. The senior authors (B.T.K. and P.B.) have been performing sleep nasendoscopy together for over 10 years, and we look back at their decade's experience. A retrospective audit study based on case notes was performed over a 10-year period (1995-2005) in a tertiary-referral practice setting. Case notes were retrieved on all patients who had undergone sleep nasendoscopy during the study period, and agreed data were extracted and analyzed. A total of 2,485 sleep nasendoscopies were performed in patients with a mean age of 44.1 years, a 4:1 male preponderance, and a mean body mass index of 27.3 kg m(-2). Sleep nasendoscopy grading correlated well with apnoea-hypopnoea index and mean oxygen desaturation. Such grading helped us define and discuss treatment options with patients. After a median follow-up period of 518 days, 72% of patients reported feeling better; 26% of patients reported no change; and only 2% of patients reported feeling worse after treatment. Sleep nasendoscopy has proved to be a useful adjunctive method to identify the anatomical site of snoring, not to mention upper airway collapse, and remains integral to our tertiary-referral practice. It has allowed us quality assessment of the dynamic anatomy of sleep-disordered breathing that most closely and cost-effectively simulates the natural situation of patients. And for targeted treatment, such assessment has been fundamental.

Aims: To compare voice quality as defined by formant analysis using a sustained vowel in patients who have undergone a partial glossectomy with a group of normal subjects., Methods & Procedures: The design consisted of a single centre, cross-sectional cohort study. The setting was an Adult Tertiary Referral Unit. A total of 26 patients (19 males) who underwent partial glossectomy and 31 normal volunteers (18 males) participated in the study. Group comparisons using the first three formant frequencies (F1, F2 and F3) using linear predictive coding (Laryngograph Ltd, London, UK) were performed. The existence of any significant difference of F1, F2 and F3 between the two groups using the sustained vowel /i/ and the effects of other factors, namely age, first presentation versus recurrence, site (oral cavity, oropharynx), subsite (anterior two-thirds of the tongue, tongue base), stage, radiation, complication, and neck dissection, were analysed., Outcomes & Results: Formant frequencies F1, F2 and F3 were normally distributed. F1 and F2 were significantly different in normal males versus females. F1, F2 and F3 were not different statistically between male and female glossectomees. Comparison of only women showed significant differences between normal subjects and patients in F2 and F3, but none in F1. This was the opposite in men where F1 was significantly different. Age, tumour presentation, site, subsite, radiation and neck dissection showed no significant difference. Postoperative complications significantly affected the F1 formant frequency., Conclusions: The study found that the formant values in patients following a partial glossectomy were altered significantly as compared with the normal control subjects. Only gender and complications and not the age, site, subsite, radiation and neck dissection were seen to influence the formant scores.

Introduction: Diagnosis of acute tonsillitis is clinical, and it can be difficult to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis, but more accurate tests take longer to deliver results. Bacteria are cultured from few people with tonsillitis. Other causes include infectious mononucleosis from Epstein-Barr virus infection, cytomegalovirus, toxoplasmosis, HIV, hepatitis A, and rubella., Methods and Outcomes: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of tonsillectomy in children and adults with acute recurrent or chronic throat infections? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2006 (BMJ Clinical evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA)., Results: We found nine systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions., Conclusions: In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics, cold steel tonsillectomy, diathermy tonsillectomy.

Tracheal rupture represents a rare but serious complication of intubation. We discuss a case of a major post-intubation rupture. After investigation with CT scan tracheoscopy and bronchoscopy a low tracheostomy was formed protecting the rupture from pressure changes associated with ventilation. The patient was managed with minimal surgical intervention, low tracheostomy with antibiotic cover and monitoring in the intensive care unit for 24 h before being woken and moved to a ward after 48 h. The patient made a full and uncomplicated recovery and was discharged 2 weeks after the original injury. Most of the literature on the subject is made up of review of case reports that conclude management of such a major tear must be with surgical repair. This however confers significant morbidity and an associated high mortality. We suggest an alternative management protocol.

This study aims to assess the management of patients with epistaxis by general practitioners (GPs) and to show whether previous experience as a junior doctor in ear, nose and throat (ENT) surgery influences their practice. A questionnaire was sent together with self-addressed reply envelopes to a random sample of 1,000 GPs. Four hundred and twenty eight GPs replied (43% response rate). Ninety-eight percent GPs see less than five epistaxis per week. Eighty-six percent GPs seek a specialist opinion for approximately one in four patients seen. Fifty percent GPs would arrange investigations. There was a wide variation in these and the first aid advice given. Fifteen percent GPs had previous experience in ENT. The only significant difference in the management of epistaxis with these GPs is that they were 2x more likely to cauterize a nose with silver nitrate (P=0.002). There is no general consensus on the management of epistaxis by GPs and despite previous experiences in the specialty as a junior doctor, this fails to have a significant impact on the day to day management of epistaxis.

Objective: Few studies have specifically assessed the risk factors for persistence or recurrence of OME in a cohort of school-age children. The generally accepted etiological factors for OME occurrence may not apply in the same way when the presence of OME over a year from original diagnosis is assessed., Methods: A cohort of 250 school-age children with unilateral or bilateral OME, identified through screening of 5121 asymptomatic children was re-examined 16 months later. All were assessed for a variety of demographic, family and medical factors. Measures included tympanometry, acoustic reflexes and a complete otolaryngologic examination., Results: At 16 months after initial confirmation of OME, 56 out of 250 children (22.4%) suffered from OME, 21 bilateral and 31 unilateral. Presence of OME at 16 months was not associated with gender, blood group, gestational age and weight, history of breast feeding, paternal education level and smoking history, history of allergy, previous use of antibiotics, or with surgery (myringotomy, insertion of ventilation tubes or adenotonsillectomy). In multiple backward-eliminating logistic regression, the only factors associated with OME presence after 16 months were episodes of AOM during the study period (odds ratio 2.75 (95% CI: 1.13-8.17), p=0.04) and younger age (odds ratio 0.53 (95% CI: 0.32-0.79), p=0.002 for each 2 years of increase in age)., Conclusion: Seventy-eight percent of school-age children identified with OME through screening will be free of disease 16 months later. The threshold for referral, or surveillance could however justifiably be lower in children who (a) have once been identified with OME and (b) are (relatively) younger, or have experienced an episode of acute otitis media.

Objective: To validate the Child Health Questionnaire (CHQ) and assess the quality of life of inner-city British children with adenotonsillar disease., Methods: The primary caregiver of a consecutive series of 43 patients referred for adenotonsillar disease to a pediatric otolaryngology clinic completed the Child Health Questionnaire. Questionnaires were analyzed for data quality and completeness, items/scale correlation, internal consistency and discriminant validity, interscale correlation, reliability estimates and external validity., Results: CHQ demonstrated excellent measuring characteristics in our population. In a comparison with healthy children, 11 out of 15 measures of quality of life were significantly depressed in our sample. Compared with children with rheumatoid arthritis, scores were equivalent in most areas, with the exception of the global health subscale and overall physical score, where our sample scored significantly lower., Conclusion: The CHQ (PF 28 version) is an accurate and reliable way of assessing the impact of adenotonsillar disease on the quality of life in children in Britain. This appears to be quite significant in most aspects of a child's life.

Objective: To study the relationship between periodontal status and peritonsillar disease/recurrent tonsillitis., Study Design and Setting: A total of 158 patients presenting over a 3-year period with peritonsillar abscess (PTA) confirmed by needle aspiration and a control group of 112 patients booked for elective tonsillectomy for recurrent tonsillitis (RT) were examined in terms of their periodontal status using the WHO Community Periodontal Index of Treatment Needs (CPITN)., Results: The mean CPITN index was 2.81 (Standard Deviation [SD], 1.10) in patients with PTA and 1.41 (SD, 0.92) in patients with RT. One hundred seven of 158 patients with PTA had significant periodontal pathology (CPITN, 3 or 4) compared with 12 of 112 patients with RT. These differences were statistically significant., Conclusion: Patients with peritonsillar abscess had an increased prevalence of periodontal disease as compared with patients with recurrent tonsillitis., Significance: There is a need to further explore this correlation and determine its nature, although it could be the result of common pathogenic factors, a causal relation cannot be excluded.