Volume 10 Issue 2 - 2017

Welcome once again to the summer edition of The Otorhinolaryngologist. There are some excellent articles of academic interest as well as some superb articles relating to service provision. Of special mention is in the audit section there is an article that focuses our minds. In the ever increasing financially deficient NHS it is good to be aware of the fiscal aspects of departments and the need to capture data accurately in a department in order to demonstrate the departments true financial worth.

I hope summer has treated everyone well and look forward to future submissions which I encourage all consultants and trainees to do. Please do contact Sanjai or myself if you are interested in contributing to the journal in any way and we would be delighted to direct you.

My Best wishes

Francis Vaz

Co-Editor of The Otorhinolaryngologist


Background: The caloric test is a generally accepted method of assessing the peripheral vestibular system. Several mechanisms of action have been postulated to account for the nystagmic response observed.

Objective: We investigated the possibility of a novel contributing mechanism relating to change in the relative specific gravity of the cupula.

Methods: Five cupulae were harvested from fresh wood pigeons, and immersed in water baths at 21°C, 41°C, 51°C, 60°C and 80°C for 5 minutes. Changes in cupular buoyancy at different temperatures were recorded.

Results: Between 21°C and 51°C all cupulae were seen to sink. At 60°C the cupulae consistently rose.

Conclusions: These observations suggest the presence of an alternative mechanism for the caloric effect involving changing cupular specific gravity with temperature.


Surgical approaches to the lateral skull base are technically challenging due to the highly complex anatomical relationships between pathology and the sensory organ of the inner ear and nearby neurovascular structures. Careful consideration must be given towards these various structures if the risks of neurologic deficit are to be minimised. This review discusses the approaches to the lateral skull base, in particular the more medial areas of the temporal bone (supralabyrinthine, infralabyrinthine, internal auditory canal (IAC), petrous apex and jugular foramen) and adjacent areas (posterior fossa, middle fossa and infratemporal fossa). It outlines the indications and potential risks and benefits of each approach and highlights the importance of a multidisciplinary approach to management of pathology.


The ‘One Airway Model’ is well recognised with established overlapping of clinico-pathological findings. Early recognition and treatment of upper airway symptoms combined with simultaneous treatment of lower airway disease may be the key to long-term airway disease control. ENT Surgeons are in a position that enables early recognition, treatment, and initiation of a multidisciplinary approach to airway disease.

A One Airway Service is an ideal way of treating patients with upper and lower airway symptoms.

The One Airway Clinic is a specialist multidisciplinary setting that benefits patient care and patient pathways, is financially cost effective, and opens numerous audit and research opportunities. We present our experience of successfully setting up and running a One Airway Clinic over the last 5 years.


Objective: LOGIC syndrome is an autosomal recessive condition which leads to increased airway granulation and possible catastrophic airway changes. This study aims to characterise ENT input into this potentially life threatening condition.

Methods: Clinical management of LOGIC syndrome patients, presenting to a tertiary centre, was reviewed from medical records.

Results: Two children with LOGIC syndrome were identified. Both developed airway abnormalities with recurrent respiratory tract infections and underwent thorough upper airway endoscopy under general anaesthetic. One required surgery for a vocal cord web, and the other micro-debridement of tracheal granulations and subsequent tracheostomy.

Conclusion: Despite its rarity, LOGIC syndrome has significant airway consequences and must be diagnosed at the earliest opportunity. Although management of affected individuals is multidisciplinary, early full airway assessment is essential.


Motor neuron disease is an incurable neurodegenerative disorder affecting both upper and lower motor neurons, resulting in progressive weakness and inevitable death due to respiratory failure. Up to 30% of patients present with bulbar symptoms and therefore may be seen first by an otolaryngologist. Furthermore, almost all patients experience bulbar symptoms in the late stages of the disease and may require the input of an otolaryngologist as part of their multidisciplinary management.


We report a rare case of a metastatic anterior neck lesion originating from a hepatocellular carcinoma in a 62-year-old man who presented with rapidly progressing, painless neck lump. The patient was investigated with CT and MRI imaging, a pathological diagnosis was achieved following fine needle aspiration and palliative care strategy implemented augmented by the siting of tracheostomy and fluoroscopic guided embolization of the tumour’s feeding neck vessels. We highlight the rarity of the tumour, and the importance of the wide multi-disciplinary approach required to generate an appropriate management strategy in such unusual cases.


Background: Payment by Results is the means by which patient care is remunerated within the National Health Service. This relies on accurate clinical coding to allow appropriate billing and remuneration. We performed an audit of our coding accuracy and completed several audit loops to assess the associated long-term effect of changes that were implemented.

Methods: Case note review over four separate time periods between 2009 and 2014 at Nottingham University Hospitals NHS Trust.

Results: Coding accuracy improved from 67.7% to 86.7% across the four cycles. Loss of income was used as an outcome measure; this reduced from £339.61 per episode to £1.56 per episode over the four cycles.

Conclusions: We have shown a large and significant reduction in potential loss of income by implementing simple improvements to facilitate accurate coding.

This is a picture of a 73-year old female referred to ENT as an emergency unable to eat and drink with odynophagia. The patient suffered a similar episode two months ago. Describe what you can see in this picture (show figure 1 to candidate). What are your differential diagnoses?


Assessment of the nose can be part of the Viva Voce in Rhinology & Facial Plastics, or the clinical short cases. You will be presented with a series of clinical photographs or a real patient, respectively. You may only have a short time to assess the nose and therefore a well-practised systematic approach is vital. This also shows the examiner of your logical approach, and that you are safe and competent to be a day 1 consultant. A useful approach to assessment for septorhinoplasty (SRP) has been covered by an earlier article.


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