Volume 4 Issue 3 - 2011

In this issue of ‘The Otorhinolaryngologist’ we have a great mix of articles that I am sure you will enjoy reading. We continue to strive to deliver educationally relevant articles that all of us, as members of ENTUK would like to read and refresh ourselves about. We aim to offer articles that cover a breadth of seniority from trainee to consultant and feel that all the articles in this issue achieve this.


Pharyngeal pouches affect 2/100 000 of the population, usually occurring in the sixth and seventh decade. Typical symptoms include dysphagia, regurgitation, chronic cough, aspiration and weight loss. Despite several theories the aetiology remains unclear. The gold standard investigation is barium swallow. Treatment is surgical via either an open or endoscopic approach with endoscopic stapling being the most frequently employed procedure in the UK.

This is a practical guide to facial flap surgery. We illustrate the key points we believe are necessary for a good outcome and indicate the salient features of themost reliable flaps. The challenges of each facial subunit is discussed. Almost all flap complications result from errors in judgement and we discuss how these situations may be avoided and resolved. An appendix of surgical tips is included.

Inverted papilloma (IP) is histologically a benign disease, but it has long been recognised as warranting aggressive surgical management. It has a propensity to be locally destructive, has high rates of recurrence, and a strong association with malignant transformation. Aetiology of IP is still uncertain, but Human Papilloma Virus (HPV) is implicated and, in a similar manner to cervical HPV infection, is proposed to have a role in malignant change occurring within IP. A review of recent literature on the aetiology of IP and possible predictors of recurrence and malignant potential is presented. Krouse’s staging of IP is discussed, with a recently published modification, adjusted for prognostic factors. Results of endoscopic and open surgery, with long-term follow-up are reviewed.

Branchial anomalies comprise a spectrum of disorders, the majority of which present in childhood. The normal embryological development of the branchial apparatus is discussed together with the developmental anomalies of each arch. The options for safe and effective surgical management are influenced by knowledge of the embryogenesis of the arch involved and relevant associated anatomy. Surgical management is aimed at complete excision of the sinus, cyst of fistula, except for fourth pouch sinuses where endoscopic cauterization is emerging as an alternative to ‘open’ surgery.

Objective: The authors present a rare case of paediatric sphenoidal mucopyocele mimicking a tumour.

Methods: A case report and literature review of sphenoid mucoceles in the paediatric population.

Results: The authors present a case of sphenoidal mucopyocele in childhood initially thought to be a rhabdomyosarcoma. We discuss the presentation, investigation and surgical management of this rare entity. We also provide radiological evidence of this pathology.

Conclusion: Paranasal sinus mucoceles are uncommon in the paediatric population; with sphenoidal mucoceles being extremely rare. Endoscopic endonasal surgery is nowadays the gold standard for treating sphenoid mucoceles.

A thirty three year old male presented to the ENT clinic with a 1 year history of nasal obstruction. On two occasions, in that year, he had presented to the emergency department with a severe right sided epistaxis where he was treated with nasal packing and cautery. He also complained of poor sense of smell but there was no history of discharge, headache or facial pains. Clinical examination revealed adhesions in the right nasal cavity; a polypoidal lesion arising from the right middle meatus and a clear post nasal space.


Peri-operative antibiotics have a significant role to play in the prevention of hospital acquired infections. Poor prescribing practice can lead to the emergence of resistant organisms and antibiotic associated infections. An audit was undertaken in which the first audit cycle identified current antibiotic prescribing practice for 139 patients. 5 patients had received antibiotics when not indicated. Following this, evidence based guidelines were issued to improve and standardise prescribing throughout the department. The second audit cycle included 128 patients and identified only 1 patient receiving inappropriate antibiotics and 1 not receiving antibiotics when they were indicated. No adverse events were identified.

A 3-year old child presents with a two-week history of a sore throat, and malaise. Over the last 3 days the child has become increasingly unwell, and for the last 24 hours has been drooling, with mild stridor. They are seen in A&E where an X-ray is performed, and on reviewing the film, the A&E team ask you to see the patient.

The Paediatric viva is an important part of the viva section and you should be able to score high in this viva. Each viva lasts 30 minutes, 15 minutes each for the two examiners. In these 30 minutes, 6 topics need to be covered. Essentially 5 minutes per topic from basics to management of the condition. There are no trick questions. The opening question is simple to get you started and feel comfortable. Competency questions are asked to check if you are safe in your approach and management. During the viva you need to move on reasonably quickly from the basic questions to management to get good scores.

The term “fellowship” can be used to describe the context of additional training, beyond that available within a Higher Surgical Training (HST) programme. Fellowships have long been undertaken by those in the final stages of training or those who have just completed training. At that stage in their careers, trainees are often looking for additional subspecialty exposure and surgical experience, to ensure that they are as competitive as possible and will be able to provide the best possible care for patients within their chosen field. Whilst obviously not required for ENT consultant practice, many of the more subspecialist consultant posts will see a fellowship as a “desirable” attribute, if not “essential”.


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