Volume 7 Issue 1 - 2014


Welcome to the first issue of the year, as usual we have several high quality articles and we are grateful to the authors for their effort in writing these excellent articles. There seems to be an endless amount of information to read nowadays form journals, NHS documents and textbooks, although I suspect the internet is slowly but surely replacing the role of the traditional textbook for the trainees wanting to ‘look up’ how to do an operation just before they are about to perform it! I do hope that you find some of the excellent reviews useful as an up to date summary on the subject being reviewed. We try to encourage a style of writing which can be easily translated into clinical practice as well as good quality material for trainees who are preparing for exams. Please do keep submitting your papers, we are delighted to have numerous articles being submitted on a monthly basis now.

The website for The Otorhinolaryngologist is being updated and I encourage you to take a look and consider the on-line CPD facility.

Enjoy the issue and please do send me any comments you have via e-mail to This email address is being protected from spambots. You need JavaScript enabled to view it.

With best wishes,

Sanjai Sood


In this article we discuss the history, physics and potential uses of lasers in ear surgery. Lasers are well-suited to otological surgery as a no-touch and vibration free tool. It is important to appreciate how lasers work in order to understand laser safety issues in addition to the various lasers available and their individual merits.



Sudden sensorineural hearing loss (SSNHL) is defined as an unexplained rapid decline in the hearing of at least 30 decibels (dB) affecting three or more frequencies over 3 days. The reported incidence is 5 - 20 persons per 100,000 per year. The vast majority of cases are idiopathic with only 10% of patients having a specific attributable cause diagnosed.

Clinical Presentation

Average age of presentation is between 40-50 years with equal sex incidence. Hearing loss maybe partial or complete and is often accompanied by tinnitus.


Investigations are targeted at excluding the known causes of SSNHL. Treatment Oral steroids are the gold standard treatment for this condition; however many other treatment strategies have been used including: intratympanic steroids, antiviral agents, carbogen, hyperbaric oxygen, and magnesium supplementation. The prognosis of SSNHL is good with the majority of patients improving within the first two weeks after the hearing loss.


Sudden sensorineural hearing loss is an otologic emergency. The majority of patients will have no identifiable cause. However, prompt treatment with oral steroids is associated with a better recovery. Emerging data has shown that intratympanic dexamethasone is at least as effective as oral steroid treatment and the addition of other agents such as carbogen and magnesium may also have a role to play in the management of this enigmatic condition.


Objective: Frey’s syndrome following submandibular gland surgery is not discussed with patients pre-operatively as it is largely considered to be rare. However literature search shows an incidence of 10% and it is thought that this figure underestimates the true prevalence as most patients are not routinely tested. This raises the question whether it should now be routinely discussed as a potential complication given that patients can find it problematic and embarrassing. The development of Frey’s syndrome following submandibular gland surgery does differ to some extent to post-parotidectomy cases and may require different management strategies. The aim of this article is to review the incidence, pathophysiology, management and implications of Frey’s syndrome occuring as a complication after submandibular gland excision.

Data Sources: Literature search via Pubmed, MEDLINE and Cochrane databases. Review methods- All identified case reports of Frey’s syndrome following submandibular gland surgery were reviewed, including a case managed at our institution. For non-English literature, abstract translation in English was reviewed.

Results: Nine articles detailing management of Frey’s syndrome following excision of the submandibular gland. More literature is required.

Conclusion: Frey’s syndrome can produce problematic symptoms that are socially embarrassing. Surgeons should consider discussing the risk of developing Frey’s syndrome after removal of the submandibular gland as is done for parotidectomy cases. More studies are required to ascertain the incidence, prevalence and best long term management options for Frey’s syndrome following submandibular surgery.


Spasmodic dysphonia (SD) is a rare dystonia of the larynx. A dystonia is a neuromuscular disorder that causes involuntary contraction of a muscle or a group of muscles. Dystonias may be focal (as in SD, which only affects the larynx), or generalised. SD is characterised by spasms of the intrinsic muscles of the larynx that result in voice breaks in running speech. Two types of spasmodic dysphonia are recognised:

Adductor spasmodic dysphonia, which is characterised by spasm of the adductor muscles of the larynx (principally the thyroarytenoid and lateral cricoarytenoid muscles). This type of SD results in a staccato-sounding voice, or sometimes a “pressed” quality to the voice.

Abductor spasmodic dysphonia, which results from spasm of the vocal fold abductors (posterior cricoarytenoid muscles), causes a quality of voice that is characterised by breathy breaks in the fluency of speech.



To gain an understanding of the anatomical and physiological changes involved in facial ageing, examine the evidence base for standardised approaches to assessing facial ageing and recommend facial rejuvenation strategies.

Materials & Methods

A review of the literature was conducted, looking for published work on the anatomical and physiological changes of facial ageing, validated methods of assessing facial ageing and current treatment options for facial rejuvenation, both surgical and non-surgical.


A number of review and original research articles were identified. Data was extracted and tabulated.


Facial aging is largely caused by skeletal remodelling, muscular facial activity, and, solar changes. Assessment is mainly clinical and subjective in nature, although objective measures using ultrasound or optical profilometry may be used. Rejuvenation is increasingly approached non-surgically (i.e. botulinum toxin, dermal fillers, lasers and other heat technologies), in addition to surgical approaches, including open, endoscopic and minimally invasive techniques.


Stereotactic navigation has developed into an extremely useful adjunct in the armamentarium of a Rhinologist. From early incarnations of the technology, manufacturers have invested incredible energy into making devices more user-friendly, more compact, more accurate and faster to set up. Devices fall into two broad categories: electromagnetic and infrared. Early electromagnetic devices were felt to be cumbersome and lacked the desired accuracy. This saw the development of infrared devices but, as time has passed, users have become more aware of certain limitations associated with these systems, which has promoted a renewed interest of manufacturers to produce better electromagnetic technologies. This may be a direct response to the expansion globally of the subspecialty of neurorhinology: endoscopic surgery of the anterior skull base and other extended applications. This article discusses the role of image-guided technology in rhinology and its benefit to ENT surgeons and patients through its regular use.


We present the unusual case of an infant born with a congenital left-sided diaphragmatic hernia, hiatus hernia and a type III laryngeal cleft that failed to close despite repeated surgical intervention. She was found to have a 2.5 cm, benign, pedunculated hamartomatous polyp of the upper third of the oesophagus. This was posterior to the cleft repair site and responsible for the recurrent repair failure. We discuss the development of cleft anomalies and review the literature on oesophageal hamartomas.



The aim of this study was to assess whether appropriateness of referrals could be improved in a single ENT unit.


Initial audit was undertaken prospectively, over a two week period. Referral standards were assessed with reference to previously locally published departmentally-developed guidelines. After the initial audit a comprehensive implementation plan was developed. Three months after implementing the change, a second prospective audit was undertaken. Data was analysed using simple statistical methods.


In the initial audit (n=133) inappropriate referrals were 40% (n=53) and of these patients 68% (n=36) were deemed "not an emergency". A re-audit was undertaken for a period of two weeks. Inappropriate referrals comprised 16% of attendees (n=14). The change of inappropriate referrals was found to be statistically significant (n=53(40%)vs.n=14(16%),X2=14.29,p<0.01).


The results showed a statistically significant improvement in referral appropriateness as the unstructured clinic system was replaced by an appointment based system.

What is this investigation?

Describe what you see. This is an axial T1 weighted MRI scan of the head/internal auditory meatus with gadolinium enhancement. Evident is a brightly enhancing mass, centred over and filling the left internal auditory canal (IAC).


Head and neck cancer treatment is based on appropriate planning through a multidisciplinary team and includes surgical, radiotherapeutic and chemotherapeutic strategies aimed at both the primary site and the neck. Neck dissection (ND) has been shown to improve survival in cases of neck metastases, even if occult. The most significant functional impact following ND is impairment of shoulder function as a consequence of spinal accessory nerve injury.


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