Volume 4 Issue 2 - 2011

This issue of The Otorhinolaryngologist contains a guest Editorial by Professor Tony Narula which as you would expect is an intelligent and articulate article on the role of the GMC in the 21st century. There are many doctors who remain wholly under impressed with the GMC and it will be interesting to see how its role develops in the next few years.

The General Medical Council This ancient body was set up over 100 years ago; partly as a result of the campaigning efforts of a Lancet editor. Its purpose was literally to register every medical graduate so that the public could be reassured that they were being treated by a bona fide practitioner. For most of its life this organisation has seemed to be sleepy and of little relevance to the average doctor. However, in the 21st century, the huge rise in patient expectations has led the GMC to be more involved in our lives and in my opinion is now struggling to cope. In the modern vernacular, is it Fit for Purpose? Let us review some of the evidence.


The prevalence of oropharyngeal squamous cell carcinoma (OPSCC) has increased to epidemic proportions in Europe and the United States of America over the last three decades. Most of this increase has been attributed to an exponential rise in the incidence of Human Papilloma Virus (HPV) associated OPSCC: HPV-16 being the most common genotype. HPV associated tumours constitute a discrete disease entity, with non-smoking, non-heavy drinking patients presenting at an earlier age than their counterparts presenting with HPV negative tumours. This article highlights evidence of this increased incidence and describes the genetic make-up of HPV. In addition, we explain the mechanisms underlying the ability of HPV to transform normal epithelial cells into cancer cells. Finally, we describe the current methods employed to detect HPV infection and conclude by highlighting a diagnostic algorithm which has been proposed as a pragmatic strategy to maximise the detection of HPV infection in oropharyngeal tumour tissue.


Neurofibromatosis type 2 (NF2) is an autosomal dominant condition caused by mutations in the NF2 gene on chromosome 22. 50-60% of patients represent de novo mutations and as many as 33% of these are mosaic for the underlying disease causing mutation.

Affected individuals develop schwannomas typically involving both vestibular nerves leading to hearing loss and eventual deafness. Schwannomas also occur on other cranial nerves, on spinal nerve roots and peripheral nerves and intracutaneously as plaques. Cranial and spinal meningiomas and spinal ependymomas are other common tumours.

The fundamental aim of management should be to maintain function and therefore quality of life whilst managing the tumour load. Management of NF2 presents a difficult problem with most patients facing substantial morbidity and reduced life expectancy.


Chronic rhinosinusitis (CRS) is a commonly reported disorder characterized by persistent inflammation of the mucosa of the nose and paranasal sinuses. Although the pathogenesis remains poorly understood, CRS is thought to be disease arising from the interaction between environmental pathogens and host innate immunity. A number of factors have been implicated as etiologic agents such as bacterial biofilms, superantigens and fungi. However, studies aiming to eradicate these environmental agents have remained inconclusive causing researchers to hypothesize that the pathogenesis of CRS may instead be due to a variety of genetic and epigenetic changes within the host response in select patients. This review will highlight current perspectives on various environmental contributors with an overview of the sinonasal innate immune system and its role in the pathogenesis of CRS.


The objective of this study was to assess the use of KTP laser in cholesteatoma surgery with regard to the rate of recurrence and preservation of the ossicular chain. This involved a retrospective analysis of cases of combined approach tympanoplasty surgery over an 8 year period. Two patients out of 13 (15%) who did not have laser used in the first stage developed recurrence observed at the second stage. Two patients out of 32 (6%) in whom the laser was used developed recurrence. The results for preservation of the ossicular chain with the use of laser in the first stage are less convincing. However, laser can be used in middle ear surgery to effectively eradicate residual cholesteatoma and potentially reduce recurrence rates.

Describe what you see.

This is a clinical photograph showing a mass in the right anterior neck. The skin over the mass appears normal and it measures approximately 2cm in diameter.

This may represent a thyroid mass. The differential diagnosis would include a lymph node or a branchial cyst.

The unilateral nasal mass is a common viva question. Candidates are usually shown a clinical photograph of a patient with an obvious polyp, or a CT scan image showing unilateral sinus opacification. The candidate is expected to demonstrate knowledge of the aetiology and investigations of such a patient, but it is also an opportunity for the examiners to evaluate the operative aspects and management of complications of functional endoscopic sinus surgery (FESS).


Objective: This case report is of a 34 year-old female with borderline personality disorder/ obsessive-compulsive disorder who presented in the Accident & Emergency (A&E) Department on repeated occasions having swallowed 121 razor blades over an eighteenmonth period.

Method: Case report. Results: Rigid oesophagoscopy was performed to remove the razor blades on each occasion. Applying the Mental Capacity Act (2005) she was found to lack the capacity to manage her treatment but the psychiatrists deemed her unsuitable for detainment under the Mental Health Act. Following frequent multidisciplinary discussions between ENT, Psychiatry and the A&E Department it was felt that removal of the foreign bodies was further escalating her behaviour and a decision was made to cease endoscopic retrieval via oesophagoscopy.

Conclusion: This case highlights the difficulties faced when managing psychiatric patients who require immediate surgical intervention. ENT surgeons need to use a multidisciplinary approach to manage these patients successfully.


Objective: To report a case of acinic cell carcinoma arising in the nasal cavity and review the related literature.

Case report: A 69 year old patient presented with nasal obstruction. A biopsy of the mass identified on clinical and radiological examination showed an acinic cell carcinoma. Further surgical excision of the medial maxilla revealed no additional tumour.

Conclusion: Acinic cell carcinoma is a malignant tumour seen most commonly in the parotid gland. These tumours only rarely occur in the sinonasal cavity. Both pathologists and surgeons need to be aware of this likelihood to avoid misdiagnosis.


Introduction: There continue to be many threats to surgical training opportunity.

Methods: A national survey was undertaken of all higher surgical trainees in Otolaryngology and head and neck surgery in the United Kingdom detailing current surgical training opportunity.

Results: There was a 51% response rate. The majority of trainees (66.7%) undertake between three and four clinics each week, with most (67.4%) performing between three and four operating lists per week; 48.5% have less than four theatre lists per week.

Discussion: The results and their implications for training are discussed, along with the need to ensure quality assurance of training posts.

Conclusion: We suspect that overall training opportunity has declined along with the number of hours worked. Training posts need robust monitoring by the appropriate organisations to ensure that they are fulfilling requirements. There is a need for a paradigm shift in training from a service-based apprenticeship to a more focused educational model.


This is a review of our experience of implanting patients with far advanced otosclerosis, specifically reviewing pre-operative predictors of differences in audiological outcome, complications (including facial nerve stimulation (FNS)) and patient satisfaction. Study Design: A retrospective case note review, including audiology assessments, was undertaken.


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