Volume 8 Issue 3 - 2015

Welcome to the last issue of 2015, which I hope you will find time to read over the festive season. This issue has a strong otology content as well as an excellent overview of frontal sinus management by Sean Carries’s team from Newcastle, which will be a welcome refresher for senior ENT Surgeons and also for trainees preparing for exams. Although the journal welcomes high quality reviews we are encouraging submissions of original research and hope you will consider submitting your research papers to the journal.

We have the usual ENT Update Conference in London this year (December 3rd) which has been very popular over the last couple of years and I look forward to seeing some of you at the meeting.

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 for 2016,

Sanjai Sood
Editor in Chief



1) To assess whether a questionnaire could safely triage balance patients into either a multidisciplinary balance clinic or an audiology led BPPV service.

2) To establish how accurate a diagnosis based on the responses to the questionnaire alone was compared to the eventual diagnosis.


50 consecutive balance clinic patients prospectively filled in a questionnaire. Eventual diagnosis was compared to predicted diagnosis from the questionnaire. Sensitivities, specificities, odd ratios and positive predictive values of the questionnaire for the common diagnoses were calculated.


All patients were safely triaged. Everyone predicted BPPV by the questionnaire had BPPV. The questionnaire demonstrated high predictive accuracies for the 3 most common diagnoses of BPPV, Meniere’s disease and migraine associated vertigo.


The dizziness questionnaire not only enables safe triage of dizzy patients to the appropriate clinic, but also has good predictive accuracies for the common causes of dizziness.


Objectives: Assess the outcomes of a multidisciplinary one-stop balance clinic in a tertiary hospital.

Design: Retrospective analysis of new referrals seen over a 3-year period (2008-2010).

Setting: Multidisciplinary one-stop balance clinic in a tertiary referral centre.

Main outcome measures: Analysis of the demographics, referral source, investigations, diagnoses and outcomes of the one-stop balance clinic

Results: 148 new patients, 52 men and 96 women with a mean age of 53.9 years (range 18-84) were seen. General practitioners referred 81% of cases. Sixty patients underwent further investigations, imaging, vestibular function and other audiological tests. 71% of patients had true vertigo. Eighty-five patients (57%) had vertigo due to an otological disorder and peripheral labyrinthine causes accounted for 64% of referrals both with and without the symptom of vertigo. Common diagnoses included (i) BPPV, (ii) Meniere’s disease or a variant, (iii) psychogenic causes such as anxiety and central causes such as migrainous vertigo and vestibular neuronitis. The majority of patients (64%) had a one-stop diagnosis and treatment plan. The remaining cases requiring follow-up were mainly those with middle ear disease being followed-up in general clinics and Meniere’s disease.

Conclusion: Our study suggests that almost two thirds of patients requiring an opinion from a secondary/tertiary care balance centre can be managed in a single appointment. It also confirms the appropriateness of the majority of primary care referrals. The level of follow up and further investigation we feel confirms the efficiency of a dedicated supra-specialist led balance clinic model.

Abbreviations: BPPV – Benign paroxysmal positional vertigo
                       DOH – Department of Health
                       VEMPs - Vestibular-evoked myogenic potentials
                       VFTs – Vestibular function tests


Objective: To evaluate the value of exercising the pharyngeal musculature to treat obstructive sleep apnoea and hypopnoea syndrome (OSAHS).

Methods: From January 2010 to April 2012, 75 patients diagnosed with OSAHS by full night polysomnography (PSG), presenting with symptoms including feeling tired, sleepy and fatigued during daytime, frequent snoring, witnessed apnoeas, or being referred by other physicians when treated for high blood pressure. Excluded were patients with tonsillar hypertrophy greater than grade II, adenoidal hypertrophy, maxillofacial deformities, laryngopharyngeal and neck tumors, clinical and biochemical evidence of hypothyroidism, neuromuscular disorders and other sleep-related diseases. Of the eligible patients 54 agreed to be treated by a regime of exercising pharyngeal musculature, the exercise group. 21 of eligible patients refused any of the course of 12 months, which constituted the control group. Both groups were matched for age, height, and weight. Investigations included a syndrome scale which was made up of modified STOP BANG questionnaire designed for assessment of the symptoms and signs of OSAHS. Additional investigations included PSG for recording the Apnoea Hypopnoea Index (AHI) and the lowest saturation of blood oxygen (LSaO2) and Body Mass Index (BMI). All patients also had 320-detector computerized tomography (320-detector CT) of the upper airway for calculating the resilience, (used as a measure which reflects the softness of soft tissue) of the pharyngeal wall of the posterior palatal area (from the level of the palate to the
lower end of the soft palate) and the posterior lingual area (from the lower end of the soft palate to the upper edge of the epiglottis). These investigations and readings were recorded before treatment, at 6-month and at 12-month. The Wilcoxon Signed Rank test was used to compare the scores of the Modified STOP BANG questionnaire. The Paired-Samples t test was used to compare the variables of AHI, LSaO2 and BMI of patients in the treatment group: before treatment and post treatment at 6–month and 12-month. Independent-Samples t test was used for comparison of the resilience of posterior palate area and the posterior lingual area in two groups before treatment and at 12-month by Statistical Package for Social Science (SPSS) V17.0, and a p value less than 0.05 was considered to be statistically significant.

Results: 6 months and 12 months after commencing exercises, the scores from an in house Modified STOP BANG questionnaire, AHI and LSaO22 were measured in the exercise group. Before treatment, in the exercise group the mean of the Modified STOP BANG questionnaire score was 17.08 (5-24), and was 14.47(2-23) at 6-months and 14.35(2-23) at 12-months; the AHI was 22.84 (5.8-64) before treatment and 15.36 (2.1-62) and 13.79 per hour (1.8-58.5 per hour) at 6-month and 12-month respectively; the LSaO22 was 74.05±13.86% at the start of the treatment and 81.18±6.89% and 81.93±13.69% at 6-month and at 12-month respectively, There was a statistically significant difference of AHI and LSaO2 between before treatment and post treatment at 6-month and 12-month. Although the BMI varied from 26.4±10.6 before treatment to 25.7±12.3 and 27.5±15.8 at 6-month and 12-month respectively, it was noteworthy that this was not a significant difference (p>0.05). At 12-month, the resilience of antero-posterior pharyngeal wall and the total pharyngeal wall area of posterior palate in the exercise group was lower than that before treatment (p<0.05). In the control group the difference was not significant (p>0.05).

Conclusion: Exercising the pharyngeal musculature is a non-invasive, non-surgical and effective method that should be considered in the management of patients suffering OSAHS. In particular patients who are elderly, those with mild to moderate OSAHS patients who are either unfit for surgery or unable to comply with Continuous Positive Airway Pressure (CPAP) or Mandibular Advancement Devices (MAD) therapy.


Petrous temporal bone cholesteatoma is defined as cholesteatoma medial to the otic capsule or labyrinth. This can arise either as a result of a congenital anomaly or by medial spread of acquired middle ear disease. While this is a benign condition its proximity to important structures, namely the labyrinth, facial nerve, trigeminal ganglion, lower cranial nerves, internal carotid artery, jugular bulb, the dura and contents of the middle and posterior cranial fossae, results in it having the potential to cause significant morbidity. Indeed these lesions commonly present with invasion of the labyrinth and fallopian canal prior to diagnosis and the earliest symptoms are typically related to hearing, balance and the facial nerve.



Frontal sinus surgery remains perhaps the most challenging aspect of functional endoscopic sinus surgery (FESS) due to the complex variable anatomy of the frontal sinus and its drainage pathway, proximity of
cribriform plate medially, orbit laterally and anterior ethmoidal artery (see Figure 1) as well as predilection for frontal recess stenosis. Poorly executed surgery can be extremely unforgiving and lead to complications both in the short and long term. Therefore, a clear appraisal of the common cellular variations of the frontal recess is pivotal in constructing a clear surgical plan preoperatively.

A 12-year-old girl attends the outpatient clinic with her mother. She is complaining of difficulties hearing at school and at home. On her audiogram some of the bone conduction thresholds are worse than the air conduction thresholds and it states ‘uncertain responses’.

A 28 year-old lady presents to clinic with a 6 week history of intermittent left otorrhoea, mild otalgia, and hearing loss. This is what you see on otoscopy. Describe your findings.


This audit set out to review the accuracy of coding in a Head and Neck Cancer centre and systematically identify ways to improve it. Coding Information, subsequent grouper (HRG) code and the final tariff paid was obtained. Changes were made to the operation note and documentation, and Complex Head and Neck procedures list and tariff. Losses of over £150,000 through coding inaccuracies were identified. Changes made triggered the correct tariff in 93% of cases after three audit cycles. This turned the Otolaryngology Speciality Business Unit (SBU) into one of the best performing in the hospital. Reviewing Complex Head and Neck procedures and implementing simple systems to improve the clinician-coder relationship, including a theatre coding checklist, vastly increases specialty income.


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