Volume 9 Issue 2 - 2016

Welcome to the summer edition of The Otorhinolaryngologist. As ever we have an educationally filled journal with some superb reviews and practical information. As ever I encourage you to use the CPD section of the website too.

I would like to take this opportunity to thank Iain Bruce, our paediatric ENT section editor, for his efforts of over the past few years as he leaves the journal. He has contributed and reviewed a large number of articles for the journal and Sanjai and myself are indebted to him. I would also like to welcome Yogesh Bajaj, who fills his place and I know holds medical education close to his heart and is warmly welcomed.

As ever I encourage all who read the journal to continue to submit and support their teams submissions which maintain the high educational value of the journal. I also remind you of our Update meeting in December 2016 the details of which are on the website.

Wishing you a wonderful summer

Francis Vaz
Co-Editor of The Otorhinolaryngologist


The total number of temporal bone fractures is decreasing, however more casualties are surviving their injuries and require otolaryngological input. Due to often multi-system injury, patients should be initially managed according to Advanced Trauma Life Support principles. Common sequelae include conductive or sensorineural hearing loss, facial nerve injury, cerebrospinal fluid leak, vertigo and tinnitus. High resolution CT is the investigation of choice, using 1-1.5 mm slices in the coronal and axial planes. Immediate, delayed and late complications of temporal bone trauma are discussed, including the controversy surrounding management of facial nerve weakness. 7-10 % of temporal bone fractures are complicated by facial nerve weakness. A framework for patient evaluation is suggested.


We present a review of the aetiology, investigation and management of cerebrospinal fluid (CSF) leaks through the temporal bone.


The high prevalence and the adverse effects of allergic rhinitis in both adults and children have led to an increased focus on improving clinical outcomes in this disease. This article outlines the clinical approach to diagnosing and treating allergic rhinitis with emphasis on new or emerging potential treatments for this condition. The importance of exact diagnosis and documentation of disease severity is emphasised. The treatment approach with single or combination therapy and the current and emerging options with allergen immunotherapy are discussed.


The term mucocele was first coined by Rollet in 1896. Onodi first described the histology of a Mucocele in 1901. Mucoceles are mucous filled epithelium lined sacs that typically fill a paranasal sinus. Macroscopically, mucoceles are thick walled grayish cysts which are histologically characterised by a pseudostratified columnar epithelial cells with few ciliated cells, hypertrophic goblet cells, fibrous thickening of submucosa and sterile mucus with cholesterol crystals.


Introduction and Aims: Ascertain how significant the reduction in incomplete excision would be with an increase in surgical excision margins. Identify any patterns of incomplete excision.

Methods: Data was collected retrospectively in the first cycle from 2007 to 2010. The implemented change was to increase the excision margin from 3-4 to 4-5mm and to compare results with gold standard dermatology guidelines (Telfer et al). The second cycle involved retrospective data collection from 2011 to 2012. Both patient demographics and pathology demographics such as the number of lesions, facial subunit, histology and completeness of excision were collected.

Results: The majority of lesions were Basal Cell carcinomas (117/151 in the first and 110/205 in the second cycles) affecting either the nose or ears of older patients in both cycles. Over half the incomplete excisions were involving the ear. 9.9% (15/151) were incompletely excised in the first cycle compared with 4.4% (9/205) in the second cycle (P=0.053). 11.1% (1/9) of the incompletely excised cases in the second cycle resulted in recurrence over an average of 17 months follow up.

Conclusions: There was an appreciable reduction in incomplete excision with increase in surgical margins. Margins are more difficult to achieve in certain facial subunits of ear e.g conchal bowl and nose e.g. columella. Consider the original size of the lesion and pre-clinical suspicion with planning excision margins. Incomplete excision will not always lead to recurrence.


Background: Unilateral tonsil enlargement frequently poses a clinical dilemma regarding tonsillectomy to rule out malignancy. There is clear morbidity associated with tonsillectomy including bleeding, the risk of anaesthesia and post operative pain. Therefore a decision has to be made considering the risks of tonsillectomy versus the risk of missing malignancy if the tonsil is not removed.

Method: A pubmed search was performed using the terms unilateral tonsil enlargement and unilateral tonsil hypertrophy.

Results: The likelihood of finding a malignancy in unilateral tonsil enlargement, with no other clinical features, is low and does not warrant a tonsillectomy in all cases. In this situation we would suggest a “watchful waiting” policy of three months. However, age, systemic and specific symptoms, and how quickly the swelling developed are important factors to take into account when assessing the patient.

Conclusions: We suggest a period of “watch and wait” in patients who present with asymmetric tonsil enlargement, with no other clinical symptoms or signs on examination.


A 45-year-old Caucasian female was seen in the outpatient department with an 8-month history of left sided otalgia, throat pain and neck swelling and a 3-day history of amaurosis fugax. On examination she was found to have a left sided level II/III neck lump. A florid peri-vascular infiltration, involving and stenosing the left common carotid artery and carotid bifurcation was identified at CT angiogram and open biopsy. Auto-immune screening was negative. Histology confirmed a diagnosis of granulomatosis with polyangiitis. We present an unusual case with specific features never previously reported in the published literature.


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